Jude Augustus Gordon
24 Sept 2013 · Coroner Donald Coutts-Wood · South Yorkshire (West)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. miscalculation of Early Warning Score leading to missed referral
“It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr [name redacted] score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different”
2. failure to trigger automatic alert for Early Warning Score exceedance
“Evidence was given at the inquest, by a consultant, that if he had been called to see Mr [name redacted] at the time his condition deteriorated, as was indicated by the Early Warning Score system should have happened, then he would have referred to critical care. He was not contacted. I was informed at the inquest that a Trust in Birmingham has a computerised system, that leads to an automatic alert to the relevant senior doctor on each occasion that a Early Warning Score exceeds the relevant level, for”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual.”
Later report
“there - were problems with the Registered Nurses' ability to calculate early warning scores accurately”
Responses
2013-0237-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action · July 2012
“work is already being taken forward. In July 2012 a report entitled National early warning score (NEWS); standardising the assessment of acute-illness severity in the NHS, was published by the Royal College of Physicians.”
Stated action
“The system operational in a Birmingham Trust depends on patient observations being recorded in the Patient Information Communication System (PICS), the Trust's rules-based clinical information, drug prescribing and administration system. As observations are entered an early warning score is generated. Depending on the score generated and the settings programmed, an automatic message can be sent to designated nursing and medical staff.”