James Fyfe
5 Jan 2015 · Coroner Peter Bedford · Berkshire
The coroner's concerns
1. raised but unlocked cot side on trolley
“It was the Jury's determination on the evidence that the cot side was able to remain in a raised but unlocked position due in part to both the design and maintenance of the trolley”
2. lack of escalation of trolley hazard notification
“The Jury were informed that MHRA were aware of the investigations of the incident trolley but that it did not appear that the issue had been escalated and notified to all Hospital Trusts and agencies that used this type of trolley”
Responses
2015-0099-Response-by-AneticAid.pdf ↗· Medicines and Healthcare products Regulatory Agency
Stated action
“We will actively continue to support this. Through our communication with the Hospital, we understand a program of safety notices and reminders to staff; highlighting the careful use of side rail, has been undertaken.”
2015-0099-Response-by-Medicines-Healthcare-Products-Regulatory-Agency.pdf ↗· Medicines and Healthcare products Regulatory Agency
Stated action · 2011
“Anetic Aid Ltd to investigate under the EU medical device Vigilance arrangements and to inform us of their findings and of any consequent action they proposed to cpRD N I BSC _ take, liaising with RBH if they required any further details of the incident”
2015-0099-Response-by-Royal-Berkshire-NHS-Trust.pdf ↗· Royal Berkshire Hospital Trust