Diana Ritchie
18 Aug 2016 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. suspected Ileus
“Mrs [name redacted] was recovering from major surgery and on her second day post operatively was suspected of having an Ileus”
2. missed escalation of NEWS scores
“there were missed opportunities to escalate Mrs [name redacted] treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team”
3. irregular observation frequency
“the observations were not taken more regularly during the night of the 5'/6"" March when it was clear that Mrs [name redacted] ! condition was deteriorating”
4. inaccurate timing of observations
“It was also suggested to me that the observations taken at 11 o'clock, 11.05, 11.10 and 11.15 were not in fact taken at those times but were taken later, after | the first relatively short lived loss of consciousness which occurred at around 11.15”
5. repeated NEWS misuse
“Finally this is not the first time | have had to write a Regulation 28 Report to this Trust which involves abuse of or failure to use NEWS properly at all”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed”
This report
“there were missed opportunities to escalate Mrs [name redacted] treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team”
Responses
2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action
“The Trust has also established a specific working group entitled”