Ruth Smith
15 Dec 2015 · Coroner Mary Burke · West Yorkshire (West)
The coroner's concerns
1. delayed medical review
“No attempts were made to ensure a doctor attended and reviewed Mrs [name redacted] between 22.30 and 00.30”
2. inadequate nursing monitoring
“The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April”
3. poor nursing documentation
“The standard of the nursing record keeping”
4. delayed medical response
“The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith”
5. lack of post-procedure monitoring
“No review was put in place following the implementation of the fluid challenge”
6. inadequate medical documentation
“The standard of record keeping and lack of records being made by the doctors who attended up Mrs [name redacted] on the evening of the 15th April and early hours of the 16th April up until the Registrar's involvement at 03.25 a.m. on the 16th April”
Responses
Ruth-Smith-Response.pdf ↗· Calderdale and Huddersfield NHS Foundation Trust
Stated action
“All patient observations are recorded on an IPAD. The use of mobile technology also allows doctors and nurses to have all the tools and information at hand to be able to respond rapidly and effectively to deteriorating patients.”