Harold Elvidge
PFD Report
Historic (No Identified Response)
Ref: 2013-0274
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
12 Feb 2014
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners Concerns
_ (1) It is clear that much work has been done by the Adult Critical Care team to learn from the mistakes made in this case. It is now not possible to obtain 500 ml bags of 5% dextrose fluid without the input of a pharmacist; and are not stored in the same place as 500ml bags of normal saline_ also heard about further training, and that sharing of these events has taken place (2) The evidence suggested that Omnicell cabinets may be available soon in E12 at the QMC . It was however clear that; although Critical Care at the City campus has Omnicell cabinets in place, this is not the case across the trust; nor even all all critical care areas in the trust: While a mistake in the context of intensive care and arterial lines may be more serious for some patients, there could be equally catastrophic outcomes for patients in non critical care settings, if there remains a risk of different types of fluids mixed up_ (3) Whilst mindful of the cost implications involved am concerned about the risk of 24th City bag drugs bags bags bag the they being future deaths occurring in other parts Of the trust which may not have as robust safety standard as Critical Care (certainly at the Hospital campus) now appears to have.
(4) It is not for me to make specific recommendations regarding the purchase of specified equipment;, but a trust-wide review of policies for safe storage of different types of fluids would reduce the risk of a similar tragedy occurring in future_ This would include issues such as where these fluids are stored, how they are packaged and labelled, who is entitled to change bags, what checks are in place,and how this is recorded,
(4) It is not for me to make specific recommendations regarding the purchase of specified equipment;, but a trust-wide review of policies for safe storage of different types of fluids would reduce the risk of a similar tragedy occurring in future_ This would include issues such as where these fluids are stored, how they are packaged and labelled, who is entitled to change bags, what checks are in place,and how this is recorded,
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and the Trust have the power to take such action.
Report Sections
Investigation and Inquest
I concluded an inquest into Mr Harold Elvidge (DoB 22.10.33 DoD 2.11.12) on October 2013. recorded a verdict of accidental death.
Circumstances of the Death
(1) It was clear in evidence that a Staff Nurse on the Critcal Care Unit at Nottingham Hospital had, on 6 October 2012, used the wrong type of fluid to keep an arterial line open. She used 5% dextrose instead of normal saline. This error was realised before Mr Elvidge died, and is consistent with the Trusts own SUI report Mr Elvidge's blood sugar levels were misinterpreted as a result of this error, and administered accordingly, resulting in brain damage, and his subsequent death, on 2nd November 2012. (2) heard evidence during the inquest about changes made in the Critical Care Unit following Mr Elvidge's death, particularly in relation to how fluid are stored, with a view to reducing the risk of different types of fluid being confused (3) The evidence of the Staff Nurse in question was that the two types of fluid (in the 500ml required for this purpose) were stored adjacent to each other in a fluid room cupboard, as well as being available in the Omnicell cabinet. The nurse obtained the fluid from the fluid room/cupboard, rather than from the Omnicell cabinet If she had obtained this from the Omnicell cabinet; she would have been prompted to confirm what fluid she intended to take out; and it is likely that the error would not have occurred,
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.