John Dodd
2 Apr 2014 · Coroner Andrew Thompson · Black Country
The coroner's concerns
1. lack of INR monitoring
“The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall”
2. unreported temperature rise
“There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff”
3. delayed A&E assessment
“There was a considerable delay on the night of the 20 April between the arrival of Mr. [name redacted] in A&E and his first assessment by_a medically qualified member of staff”
Responses
2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust.pdf ↗· The Dudley Group NHS Trust
Stated action · within two months
“A written guideline will be developed to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants, such as warfarin.”
Stated action · within four months
“The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patient's vital signs fall outside normal parameters.”
Stated action
“The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review when presenting to the Emergency Department.”