Maureen Ellett
31 Oct 2014 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
The coroner's concerns
1. incomplete A&E documentation
“(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were”
2. inadequate triage documentation
“The second Triage Nurse in A & E did the assessment on Mrs. [name redacted] at the end of a 12% hour shift which was due to end at 20:00 hours on the 16th June, 2014.”
3. inexperienced staff providing care
“Staff Nurse in the Clinical Decisions Unit on the night of the 16th / 17th June 2014 was an Agency Nurse who had had no previous experience ever of working in the Emergency Department or a Clinical Decisions Unit.”
4. failure to verify observations timely
“The Hospital's own Observation Policy states that if N.E.W.S observations are taken by a | Health Care Assistant they should be checked within 30 minutes by the Senior Nurse”
Responses
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action
“We agree that there were shortcomings in the record keeping when Mrs [name redacted] first arrived in the Emergency Dept. Since then, several changes have been made. Agreement has been reached with the South East Coast Ambulance NHS foundation Trust (SECAMB) that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives.”