James Quinton
22 Feb 2018 · Coroner Nicola Mundy · South Yorkshire (East)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. poor quality nursing notes and lack of observation chart information
“During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring. Clearly poor record keeping has significant implications for patients.”
2. wrong drug or wrong amount or wrong method of administration
“2) Furthermore, during the course of the resuscitation a decision was made for Mr [name redacted] to be given 4 mgs of Noradreneline. This was to be given as an infusion. Unfortunately, this was actually given as a 4 mg iv bolus. Although the records suggest this did not have a detrimental effect on Mr [name redacted] (his blood pressure had been exceptionally low) this clearly could be highly significant for other patients. It also raises the question of other patients being given either the wrong drug or the”
3. absence of checking procedure for drug administration
“It would seem sensible to have some checking procedure by the person administering the drugs checking with the person who had prescribed it to make sure their understanding is correct. From the evidence | heard it seems there are no such procedures in place.”
Linked reports
Closely relatedConfidence 0.92 · high
This report
“During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring.”
Later report
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
Responses
2018-0056-Response-by-Doncaster-Bassetlaw-Teaching-Hospital.pdf ↗· Doncaster Royal Infirmary
Stated action · end of April
“1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department. The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the”
Stated action · end of April
“a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end of April to look at systems and processes for working together within the Resus area.”
Stated action · end of April
“The first meeting is scheduled for the end of April to look at systems and processes for working together within the Resus area.”