Maria Howell
27 Jan 2022 · Coroner Michelle Brown · Essex
The coroner's concerns
1. lack of qualified nursing staff to reinsert RIG tube
“That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical. That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention.”
2. delayed ambulance call after RIG tube dislodgement
“The nurse on duty noticed that the RIG tube had fallen out, but was not trained to reinsert, she delayed calling for an ambulance so the timings as to when this fell out was unknown. She was taken to Basildon A & E and at the hospital some hours later she had the PEG button reinserted and was discharged home. The same nurse was on shift that evening and Mrs [name redacted] became unwell, around 7pm. No ambulance was called by the nurse until the day nurse came on duty, some 12 hours later. Mrs [name redacted]”
3. delayed diagnosis and treatment of peritonitis
“Mrs [name redacted] was taken by ambulance where it was diagnosed that she had Peritonitis and sadly passed away on the 28th September 2019”
Responses
No published response was found on judiciary.uk.