Elsie Mallalieu
17 Nov 2014 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. inappropriate ward placement
“During the course of her relatively short stay in the hospital she was moved to Ward 41 which, as agreed in evidence by senior medical staff, was an inappropriate ward for her.”
2. lack of staff training on high flow oxygen equipment
“She was entirely dependent on high flow oxygen, but none of the staff on ward 41 was trained to use this equipment.”
3. inadequate medical and nursing documentation
“The medical and nursing notes on ward 41 were woefully inadequate, and failed to record some of the most basic care which was, or ought to have been, given.”
4. insufficient staffing to monitor deteriorating patient
“Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and”
5. failure to escalate patient to higher level of care
“A Consultant agreed with my conclusion that this patient was”
6. administration error of intravenous antibiotics
“she was administered antibiotics for this condition but the nursing staff had failed to”
Responses
2014-0501-Response-by-Tameside-Hospital-NHS-Trust.pdf ↗· Tameside NHS Foundation Trust
Stated action · 24 April 2014
“Response Following detailed investigations, action has been taken to minimise the risk of inappropriate transfer occurring in the future. Training has been provided to doctors in the Orthopaedic Department to make them aware of the following: (a) That a patient's consultant or alternatively a senior member of the consultant's team must be involved in any decision to transfer a patient between specialties and / or ward areas and that the discussion about transfer and the decision taken must both be clearly”
Stated action
“Page 8 of the Trust's internal investigation report confirms the outcome of the Trust's investigations; that at the time of handover from the Trauma Unit to Ward 41 the need for high-flow oxygen therapy and the skills to use that equipment should have been discussed and resolved before any transfer was completed. The on-call physiotherapist who was familiar with the equipment for high-flow oxygen attended the ward to review Mrs [name redacted] and was available to assist the nursing staff with it.”
Stated action
“The Trust's internal investigation identified deficiencies in the record keeping in this case and is undertaking a review of its current training on record keeping standards. Such training will reinforce the need for clarity and completeness.”
Stated action
“staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs [name redacted] was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained. Nurse staffing levels are being monitored through multiple assurance sources including the Trust Board Hard Truths paper. Additionally, the Trust's”
Stated action
“The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration. In relation to the example given of a doctor who attended on Mrs [name redacted] at 2.30am and "guessed”
Stated action
“Although, as addressed above, Mrs [name redacted] should not have been transferred to Ward 41 from the Trauma Unit it is certainly not the case that she was "written off'. Nevertheless, admittedly she was a very ill patient with a poor prognosis and this was supported by the Trust's commissioned independent expert report of Consultant [name redacted] which was sent to your offices prior to the inquest.”