James Fletcher
1 May 2019 · Coroner Tim Holloway · Blackpool & Fylde
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of guidance and protocols for care of non‑verbal patients with learning disabilities
“I am concerned that, whilst there exist policies concerned with the provision of care to those patients with learning disabilities there may be a lack of disseminated guidance and protocols for the care of those patients who are unable to communicate verbally. It is of particular concern that, in such cases, measures should be identified by which a method of communication can be established and/or appropriate measures should be put in place to compensate for any lack of communication verbally,”
2. inadequate record keeping and retention of records
“There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records. Whilst it is understood that "NEWS 2" is being introduced and supersedes the early warning score system being used at the time of the Deceased's death and whilst the early warning score system in use at the time does not, therefore, form the subject matter of this report”
3. miscommunication between medical and nursing staff
“I am concerned that communications between medical staff, between nursing staff and between medical and nursing staff should be accurate and that it should be ensured that they have been understood. By way of example, in this matter, there was either miscommunication or misunderstanding of the position concerning the taking of an abdominal x‐ray and an apparent miscommunication or misunderstanding of the level of expertise being offered in the interpretation of a chest x‐ray.”
4. lack of knowledge about PEG surgery risks
“I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post‐operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis”
5. essential medication not readily accessible
“The evidence disclosed that certain essential medication had not been retained in close proximity to the Deceased, where it was required. I am concerned that, in such circumstances, essential medication may be required urgently to protect the life of a patient and that systems should be robust enough to ensure that it is available in the correct location.”
Linked reports
Closely relatedConfidence 0.82 · moderate
Earlier report
“found on hearing the evidence that records from both departments from 16.52 onwards are, inaccurate, infrequently made, disjointed and and incomplete causing them to be unreliable and affected continuity of care.”
This report
“There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records.”
Responses
2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-Trust.pdf ↗· Blackpool Teaching Hospitals NHS Foundation Trust
Stated action
“The Trust has an Accessible Information Standard Policy allowing for production of information in different languages and formats, including braille.”
Stated action · end of this month
“A revised business case is in development and due for consideration by Executive Directors by the end of this month.”
Stated action
“The Trust recently introduced a revised early warning score NEWS2 which is a national programme for the recognition of patients who require assessment.”
Stated action
“staff should be alert to the risk of peritonitis in any patient who has undergone abdominal surgery and | have issued a Red Alert to all staff in the light of this serious incident”
Stated action
“The practice in the Trust is that all patients on admission have their medication reviewed by the admitting doctor and are then seen by a clinical pharmacist and drugs are prescribed for use within the Trust”