Tammy Watkins
5 Jan 2024 · Coroner Laurinda Bower · Nottingham and Nottinghamshire
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. preventable deaths due to failure to recognise deterioration in mental health patients
“Poor Quality Acute Physical Healthcare in the mental health setting [the deceased]'s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention”
2. inconsistent vital sign monitoring
“Failure to Adhere to the National and Local National Early Warning Score (version 2) Policy This is a repeated theme identified at inquest and in previous Prevention of Future Death reports.”
3. unmanaged ingestion risk of foreign objects
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust”
4. delayed emergency response
“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. It had been recognised early in the day by the Security Team that [the deceased] may require an out of grounds medical transfer, but it was not until much later in the afternoon, when [the deceased] was in cardiac arrest, that an ambulance was called”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues.”
This report
“Poor Quality Acute Physical Healthcare in the mental health setting [the deceased]'s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention.”
Closely relatedConfidence 0.85 · high
Earlier 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”
This 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.”
Closely relatedConfidence 0.90 · high
This report
“A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust.”
Later report
“I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance.”
Responses
2024-0017-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
Stated action · next 12 months
“The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”