Clive Davies
PFD Report
Historic (No Identified Response)
Ref: 2017-0074
No published response · Over 2 years old
Response Status
Responses
0 of 2
56-Day Deadline
7 Jun 2017
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
Coroner’s Concerns
the matters of concern as follows
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
Report Sections
Investigation and Inquest
On the 7th September 2016 I commenced an investigation into the death of Clive Davies. The investigation concluded at the end of an inquest on the 15th March 2017. The conclusion of the inquest was that of a narrative conclusion “Clive Davies died from the complication of a head and neck injury which he sustained when he fell down the stairs at his home address. The precise cause of the fall is unknown but is likely to have been due to the medical condition which he suffered with.”
Circumstances of the Death
The deceased, who was known to have fallen several times since January 2016 and who was generally in poor health, fell down the stairs at his home address on the 22nd August 2016 he was conveyed to the Royal Glamorgan Hospital where a CT scan revealed serious head injury (Intraventricular Haemorrhage) and a Cervical Spine Fracture. Initially his observations were stable but a noticeable deterioration occurred on the 24th August where upon a further CT head scan took place which revealed progression of the intracranial bleed. He was not deemed suitable for surgical intervention. His condition fluctuated and he appeared to be making some progress although his family maintained that he was deteriorating throughout his hospital admission. In the early of 30th August he was found unresponsive in his bed and could not be revived. He was declared deceased shortly after.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Recording of routine observations
Mid Staffs Inquiry
Missed and inaccurate patient observations
NEWS score over-reliance
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.