Mary Whitlock
17 Dec 2024 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. administration of morphine to patient with documented allergy to tramadol codeine and buprenorphine
“Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine. Naloxone was required to reverse the effect. Whilst this die not cause or contribute to this death this matter was not part of the Trust review, and no safeguarding was raised.”
2. understaffing of Notley Ward
“Evidence of clinical witnesses is that Notley Ward was (at the time of this death) and remains understaffed despite escalation within Trust”
3. lack of discharge summary and safety netting advice for discharged head injury patient
“No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury”
Responses
2024-0692-Response-from-Mid-South-Essex-NHS-Trust-.pdf ↗· Mid and South Essex NHS Foundation Trust
Stated action · 08:15AM Monday-Friday
“implemented a daily staffing huddle which takes place at 08:15AM Monday-Friday. The huddle review the staffing position across the site and senior colleagues make immediate redeployment/mitigation plans as required”