Patricia Forshaw
8 Sept 2017 · Coroner Alan Walsh · Manchester (West)
The coroner's concerns
1. ambiguous appointment card telephone number leading to misdirected emergency contact
“The telephone number on the card given to the deceased when she was discharged from the Hospital related to appointments only but the purpose of the number is ambiguous and when the deceased's husband telephoned the number on the card in the early hours of the 20" October 2016 he believed he was speaking to the Emergency Department, particularly in view of the fact that he was given advice to give paracetamol to the deceased”
2. lack of documentation of emergency telephone advice
“The telephone call from the deceased's husband to the Hospital in the early hours of the 20 October 2016 and the advice to give paracetamol was not recorded in any Hospital records”
3. failure to document and communicate clinical observations to doctor
“the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased”
4. absence of routine observations and blood tests for infected wound
“routine observations (pulse, blood pressure, respiratory rate, temperature) and blood investigations should have been conducted when the deceased presented to the Out Patient appointment on the 21* October 2016”
5. lack of formal escalation for serious incident review
“there had been a discussion between Consultants in the Emergency Department in relation to the treatment and care of Mrs [name redacted] but the treatment and care of Mrs [name redacted] had not been escalated as a formal report for consideration of a Serious Incident Review”