Pamela Evans
4 Oct 2019 · Coroner Amy Street · Bedfordshire and Luton
The coroner's concerns
1. inconsistent calling of critical care outreach team
“i) A mismatch between: (a) on the one hand, the expressed intention of senior nursing staff as to when nurses should call the critical care outreach team if the relevant medical team is unable to attend, namely that nurses should call when they have concerns about a patient, irrespective of the patient's NEWS score and (b) on the other hand, the understanding of at least some nurses that they cannot or will not call the outreach team, despite having concerns, unless the NEWS score exceeds a”
2. lack of training assessment for outreach team calling
“The absence of a means (eg audit) of assessing the understanding held by those who need to know (eg nurses), of when the critical care outreach team could/should be called; and therefore a lack of knowledge within the Trust of whether training on this point has been effective and comprehensive to all relevant people or whether further/different training needs to take place”
3. limited response capability of critical care nurse
“Even if the critical care outreach team had been called, a doctor would not initially attend, but rather a critical care nurse with limited power to take action - eg could not request a CT scan”
4. inaccurate NEWS scoring
“Incorrect recording of this patient's NEWS and associated score after her fall which could in other circumstances influence whether/when potentially life- saving measures for future patients take place”
5. missed learning from serious incident investigations
“That points (i)-(iv) had not been detected by the Trust despite its carrying out of a serious incident investigation”