Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of national guidelines for post-procedure monitoring after nerve block
The earlier warning
Pamela Hands · 18 Dec 2017 · Emma Carlyon, Cornwall and the Isles of Scilly
“At the time of the death were no National Guidelines to advise on the need to monitor patients post procedure or application of the anaesthetic nerve block”
judiciary.uk/prevention-of-future-death-reports/pamela-hands
What was promised
Stated action 1 · response to Pamela Hands (18 Dec 2017) · stated timescale: within the next 12months
“covers the management of hip fractures will be updated to reflect and emphasise the need for appropriate monitoring of all patients particularly those in pain pre or post procedure. This document is due for renewal within the next 12months.”
judiciary.uk/…/2017-0373-Response-by-British-Orthopaedic-Associ…
What recurred
- 25 Jan 2019 · Stephen Pettitt · Karen Dilks · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Pamela Hands · 18 Dec 2017
“At the time of the death were no National Guidelines to advise on the need to monitor patients post procedure or application of the anaesthetic nerve block”
Later · Stephen Pettitt · 25 Jan 2019
“that consideration to the creation of appropriate national guidelines in respect of the implementation of any New Interventional Procedure programme and the training required in respect thereof should be considered.”
What happened next
No web check of the stated actions has been published for this chain.