Michelle Whitehead
19 Jan 2022 · Coroner Elizabeth Didcock · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. sedation medication dosing
“Unclear dose/type of sedation medication given, possible excess dose given, poor documentation”
2. recognition of declining condition
“Delayed recognition of Mrs [name redacted] declining condition”
3. lack of medical documentation
“No medical clerking from admission until her collapse”
4. lack of consultant oversight
“No Consultant involvement after admission”
5. unreachable duty doctor
“Inability to reach Duty Doctor for deteriorating patient”
6. delayed emergency response
“Delay in calling paramedics”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Delayed recognition of Mrs [name redacted] declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in”
Later report
“There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service.”
Responses
2022-0016-Response-from-Nottinghamshire-Healthcare_Published.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
Stated action · mid-April 2022
“the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be wom on a lanyard alongside individual identification badges, acting as an immediate within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.”
Stated action · by end of May 2022
“Additionally, the Division is rolling out handheld devices that allow staff to immediately enter automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Wade Unit”
Stated action · 9 March 2022
“The Trust Resuscitation committee is convening (initially on 9 March 2022) to review the Rapid Tranquilisation Policy and will explore, review and determine what actions should be taken should @ patient fall asleep post rapid tranquilisation administration.”