Harry Stobie
4 Aug 2023 · Coroner Tom Osborne · Milton Keynes
The coroner's concerns
1. lack of monitoring after PEG insertion
“once the PEG tube was inserted at Milton Keynes Hospital it seems that the deceased's deteriorating condition was not monitored closely even though he was complaining of abdominal pain soon after the procedure was completed . His concerns were not escalated to a senior doctor for consideration of a possible bleed. The procedures and protocols following PEG insertions should be reviewed.”
Responses
2023-0284-Response-from-Milton-Keynes-University-Hospital-1.pdf ↗· Milton Keynes University Hospital
Stated action
“the team has elected to incorporate use of a pain score and/or a trigger of an AMBER score on the NEWS-2 system in order to prompt earlier escalation and to reduce the threshold for consideration of a CT scan”