Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed surgery beyond 36 hours
The earlier warning
Maureen Harrop · 14 Sept 2022 · Alison Mutch, Manchester South
“The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs [name redacted] case that was not achieved due to a lack of theatre capacity.”
judiciary.uk/…/maureen-harrop-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Maureen Harrop (14 Sept 2022) · stated timescale: none stated
“The Trust has now been able to reinstate previous care pathways due to a decline in the national incidence of Covid positive cases. This means that the bed base of trauma and orthopaedics has been increased to near pre- pandemic levels”
Stated action 2 · response to Maureen Harrop (14 Sept 2022) · stated timescale: none stated
“The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”
Stated action 3 · response to Maureen Harrop (14 Sept 2022) · stated timescale: none stated
“For those patients who can proceed to surgery, this will be scheduled to take place within the 36 hour timeframe to support compliance with NICE guidance. If this is not possible due to a theatre not being available, an urgent review of the entire trauma and elective lists that day will be undertaken. A clinical and operational discussion determines how the patient can be accommodated, and a plan is then devised. The detailed plan is then enacted with the approval of the Divisional Management Team”
3 further stated actions are listed on the full chain page.
What recurred
- 22 Nov 2023 · Kathleen Booth · Emma Serrano · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Maureen Harrop · 14 Sept 2022
“The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs [name redacted] case that was not achieved due to a lack of theatre capacity.”
Later · Kathleen Booth · 22 Nov 2023
“There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time.”
What happened next
No web check of the stated actions has been published for this chain.