John Matthews
29 Jan 2015 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. triaged without triage nurse seeing ambulance Patient Report Form
“Whilst in the Emergency Department at Stepping Hill Hospital, he was triaged without the triage nurse having seen the ambulance Patient Report Form.”
2. locum doctor unable to access PRF or full system
“The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system.”
3. neurological observations not instituted
“It was agreed by the ED consultant giving evidence that neurological observations ought to have been instituted, but they were not.”
4. unnecessary delay in head CT scan
“There was an unnecessary and to some extent unexplained delay in sending him for a CT scan of his head.”
Responses
2015-0034-Response-by-Stockport-NHS-Trust.pdf ↗· Stockport NHS Foundation Trust
Stated action · 24 March 2015
“The following system is in place for all patients arriving by ambulance to Stockport NHS Foundation Trust: the ambulance personnel will deliver a verbal handover to the triage nurse whilst a hard copy of the ambulance Patient Report Form (PRF) is left with the reception staff. This is then scanned by reception staff into the ED electronic system (therefore accessible to all) and the hard copy is taken to the main base in the ED clinical area.”