Hilary Thomas
28 Jun 2023 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. patient overload
“the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume”
2. unscheduled return of over‑70 patient with severe pain
“Mrs [name redacted] reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours”
3. delayed CT scan due to misunderstanding of blood test requirement
“The doctor treating Mrs [name redacted] on her second attendance decided to wait for blood test result before ordering a CT scan under the misunderstanding that these were required to assess the possibility of renal toxicity from dye used during the scan”
Responses
2023-0216-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2023-0216-Response-University-Hospitals-Birmingham-NHS-Foundation-Trust.pdf ↗· University Hospitals Birmingham NHS Foundation Trust
Stated action · 31 October
“The Trust will ensure that relevant staff are aware of this guidance and will ensure that it is disseminated to all staff managing acute surgical emergencies. Following Mrs [name redacted] death the following actions are being taken to share the learning from this incident: 1. Locally: Laminated posters of the joint statement will be displayed in acute surgical areas at all acute sites. A new trust policy that directly reflects the June 2023 guidelines will be published and disseminated to all clinical”