June Parlour
28 Sept 2020 · Coroner Lincoln Brookes · Essex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of awareness of morphine guidelines
“staff on the ward (whether doctor or nurse) were not familiar with either the national morphine guidelines (BNF) or indeed those of the hospital”
2. incorrect safe dose of IV morphine quoted in report
“hospital's own Serious Incident report had incorrectly quoted the hospital's guidelines as to the safe dose of IV morphine”
3. inadequate education and audit of safe morphine doses for new doctors
“adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive, and how this is audited”
4. outdated hospital morphine guidelines
“hospital's own guidelines regarding morphine administration for acute pain management have not been revised since 2013 and are at odds with the current BNF guidelines”
5. poor drug chart design for IV morphine titration
“drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine”
6. nurse's lack of confidence to challenge prescription
“nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.”
Later report
“The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.”
Responses
2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf ↗· East Suffolk and North Essex NHS Foundation Trust
Stated action
“We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF).”