Michael Flynn
10 Jan 2019 · Coroner Alison Mutch · Manchester (South)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of EWS monitoring
“There was no monitoring of Mr [name redacted] EWS in the post operative recovery area. Observations were taken randomly but not incorporated into an EWS. Trust policy was that this should have happened. Staff dealing with Mr [name redacted] therefore were unaware of his EWS scores. On arrival at the ward his initial score was 11 under the EWS system .He arrived with a standard care plan.”
2. non adherence to EWS protocol
“The trust had a clear protocol regarding monitoring and trigger points for regularity and escalation in relation to EWS. Whilst Mr [name redacted] was a patient on the orthopaedic unit the Trust policy was not adhered to. For example the inquest heard that in the 18 hours preceding his death he did not see a doctor and he was not reviewed despite the EWS scores requiring this to happen.”
3. incomplete EWS scoring
“His final two EWS scores did not include all relevant information despite a visibly clinically deteriorating position. His penultimate EWS was recorded at midnight. That was five (and did not include blood pressure). A further score should have been taken 15-30 minutes later. It was not and no further scores were taken for a further 4 hours and 50 minutes. At 04.50 his score was recorded at 10. He then became unresponsive.”
4. delayed medical review
“He was only seen by a Doctor when a crash call went out and not in the period when there was a deteriorating clinical picture contrary to the Trust policy.”
5. lack of communication between doctors and nursing staff
“The ward was staffed by ward doctors throughout the day but there was no documeniation to suggest communication between the ward doctors and nursing staff in relation to Mr [name redacted] and his deteriorating picture”
6. absence of consultant review
“Mr [name redacted] was not seen by a consultant after he left the post operative area. A ward round should have taken place the day T after his operation but did not take place because the consultant was otherwise engaged. No arrangements were made for it to be rearranged”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The documentation held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.”
This report
“The ward was staffed by ward doctors throughout the day but there was no documeniation to suggest communication between the ward doctors and nursing staff in relation to Mr [name redacted] and his deteriorating picture”
Responses
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust.pdf ↗· Tameside General Hospital
Stated action
“the Matron for theatres has met with and provided feedback to the individual staff members involved in the post-operative recovery period with respect to completing the appropriate documentation.”
Stated action
“the Matron for theatres has taken measures to improve communication with ward staff, by introducing a formal telephone handover for patients identified as 'high risk' detailing the current NEWS score and management plan in place.”
Stated action
“The Matron for Theatres has also provided assurances that an audit of recovery documentation has been commissioned to provide evidence of compliance and continuous monitoring.”
Stated action
“The Matron for the Orthopaedic Unit has provided assurances that formal discussions have taken place with the nursing staff identified through our investigation as failing to comply with Trust Policy in respect to the regularity, recording and appropriate escalation of NEWS observations, and consideration given to identified support or training needs.”
Stated action
“The Matron for the Orthopaedic Unit has advised that the learning from our investigation into the care provided to Mr. [name redacted] was shared and discussed at the Divisional Senior Nurses meeting and subsequently, has been raised again on receipt of your Se areng the Consultant [name redacted] who ied the Trust investigation, has provided his assurances that the case has also been raised and discussed at the Orthopaedic Speciality meeting, which is attended by all grades of Orthopaedic medical”
Stated action
“the Trust Patient Safety Team have drafted and distributed a 'Time out for Learning' bulletin focusing on the importance of completing, recording and escalating NEWS observations appropriately.”