Natasha Raghoo
6 Mar 2014 · Coroner David Skipp · West Sussex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of training in CPR and defibrillator use
“During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward.”
2. inconsistent vital sign monitoring
“Physical observations of blood pressure, pulse and temperature were sporadic and few in number. This was cause for concern as [the deceased] had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action.”
3. failure to perform ECG despite availability
“Whilst under the care of the Dene,and on antipsychotic drugs and with a raised blood pressure an electrocardiogram was not carried out because all routine ECGs are performed by a visiting nurse from a General Practitioners surgery on a set day of the week. An ECG machine is available within the hospital but is not routinely used.”
4. inconsistent handovers with agency staff
“Staff handovers occur twice daily in the morning and evening. Those finishing a shift hand on information about the patients to the incoming shift. It was apparent that communication was inconsistent, particularly when bank or agency staff were involved.”
5. inadequate family communication
“Communications between staff and family were haphazard the policy of involving family in care planning was not clear.”
6. unclear GP service access policy
“The policy of access to GP services was not clear leading to misunderstanding by the Princess Royal as to where to send a report.”
Linked reports
Closely relatedConfidence 0.78 · moderate
This report
“Communications between staff and family were haphazard the policy of involving family in care planning was not clear.”
Later report
“That upon [the deceased]'s discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the tisks being explicitly discussed.”
Responses
2014-0100-Response-by-Partnership-in-Care.pdf ↗· Partnerships In Care
Stated action
“The nursing staff had all been trained in CPR and use of the defibrillator, and indeed | understand that the training records were supplied to you confirming this.”
Stated action
“PiC is always seeking to improve its practices and | hope that it will assure you to learn that, since the time of the sad death of the patient, we have made a number of changes in our procedures. In particular, the company has introduced enhanced physical health monitoring procedures. These include, as a minimum, daily physical observations for each patient which are conducted every morning by the trained nurse, at the time of the first medication administration round.”
Stated action
“The changes relating to the physical health screening are outlined in Issue 2 above”
Stated action
“We understand the importance of ensuring that the handover between shifts is comprehensive and effective and, since the time of the death, PiC has reviewed and standardised its handover procedures across the company. The new procedure includes the completion of a formal handover document which is signed by the Nurse in Charge of the shift confirming that a complete handover has been given.”