Simon Healey
6 Dec 2018 · Coroner Heidi Connor · Berkshire
The coroner's concerns
1. lack of critical care capacity in private hospitals
“I believe that the NEWS policies in place at private hospitals should be reviewed. This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell. Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant's availability to attend and review the position. The Royal College of Physicians NEWS trigger th”
2. inadequate post-operative monitoring in general wards
“We heard evidence that Berkshire Independent Hospital has performed 5 operations like this between 2016 and 2018, including [the deceased]'s operation. Whilst the surgeon had experience of the procedure in the NHS, post- operative management is carried out in a general ward, caring for patients from a range of specialities. Nursing staff in this context may well never have cared for a patient after this operation, and not be familiar with the signs and symptoms to be aware of and in particular, to alert”
3. inadequate investigation of critical incidents
“The final concern relates to Berkshire Independent Hospital only. The hospital investigation into these events was inadequate, particularly in relation to the decision-making of the key player in this matter, r There are 2 sentences in the report regarding his involvement, and it would appear, a simple acceptance of his view that this was no more than a recognised complication of this procedure. This organisation will not learn from sad cases like this if their own investigations are inadequate.”