John Heffron
18 Aug 2022 · Coroner Kevin McLoughlin · West Yorkshire Eastern
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delay in initiating CPR
“The inquest found there was a delay between the patient being found in an unresponsive condition and CPR being initiated”
2. lack of familiarity with crash call system
“The lady working as a bank nurse in the Emergency Department (ED), who found the patient unresponsive, admitted to the Trust's investigator she was not familiar with the crash call system”
3. experienced nurse did not press crash call buzzer
“The experienced nurse alerted to the situation also did not press the crash call buzzer”
4. lack of audit or verification of training
“It is acknowledged that some additional refresher training has been carried out since this incident”
5. uncertain agency staff qualifications and training requirements
“It was unclear whether the Trust's contractual arrangements with nursing agencies stipulate the requirement for those supplied to (a) be professionally qualified (b) have current training to specified standards and (c) have undergone appropriate induction”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The evidence revealed that in 2015, the Trust did not hold records of the training received by individual nurses. Instead, it was left to each individual nurse to maintain their own training records.”
This report
“(9) It was unclear whether the Trust's contractual arrangements with nursing agencies stipulate the requirement for those supplied to (a) be professionally qualified (b) have current training to specified standards and (c) have undergone appropriate induction to the ED.”