Felice Banfield
30 Jan 2023 · Coroner Andrew Cox · Cornwall and the Isles of Scilly
The coroner's concerns
1. lack of clarity about NIV availability
“A lack of clarity about if and when NIV can be offered to admitted patients”
2. failure to involve respiratory team
“A patient admitted into RCHT with a respiratory element to her underlying condition was not brought to the attention of the respiratory team”
3. missed deterioration detection
“failure to recognise a deterioration in the presentation of a patient which could have triggered a request for repeat bloods and revealed the worsening acidosis before an AKI developed”
4. dehydration risk
“use of food and fluid charts to make sure a patient is not becoming dehydrated and is having adequate calorific intake”
5. lack of care continuity
“for patients who stay on AMU longer than usual, ensuring there is some continuity in medical or nursing care, so a deterioration in presentation can be recognised promptly”
Responses
2023-0032-Respomse-from-Royal-Cornwall-Hospital-.pdf ↗· Royal Cornwall Hospital
Stated action · once the revised SOP has been signed off
“During the COVID-19 pandemic, the guidance of when and where NIV could be delivered was regularly changing as more was learnt nationally about the virus. If a patient is admitted to RCHT now, usually on home NIV and stable, and can manage their own mask and ventilator as they would at home, they can be managed on any medical ward. There would only be a concern if the patient is positive for COVID-19 or flu and then they would need to be accommodated in a side room. However, if patients on long”