Ronald Compson
PFD Report
All Responded
Ref: 2018-0030
All 1 response received
· Deadline: 21 Mar 2018
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
21 Mar 2018
All responses received
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
1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on call Doctor.
2. There were two separate incidents of vomiting and poor record keeping of when these occurred.
3. There was poor communication to the family about the initial fall.
2. There were two separate incidents of vomiting and poor record keeping of when these occurred.
3. There was poor communication to the family about the initial fall.
Responses
Response received
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Dear Mr Siddique,
Re: Response to Regulation 28 Report to Prevent Future Deaths – The late Mr Ronald Compson
I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest and your ruling on 18 January 2018, in respect of the late Ronald Compson. I should extend again the condolences of the Trust to Mr Compson’s family.
The MATTERS OF CONCERN are as follows:
1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on-call Doctor.
2. There were two separate incidents of vomiting and poor record keeping of when these occurred.
3. There was poor communication to the family about the initial fall.
The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.
The enclosed action plan confirms the actions taken subsequent to the investigation and target dates for completion of those actions.
I trust the information provides assurances to you that The Dudley Group NHS Foundation Trust has taken appropriate action to address the matters of concern raised.
Re: Response to Regulation 28 Report to Prevent Future Deaths – The late Mr Ronald Compson
I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest and your ruling on 18 January 2018, in respect of the late Ronald Compson. I should extend again the condolences of the Trust to Mr Compson’s family.
The MATTERS OF CONCERN are as follows:
1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on-call Doctor.
2. There were two separate incidents of vomiting and poor record keeping of when these occurred.
3. There was poor communication to the family about the initial fall.
The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.
The enclosed action plan confirms the actions taken subsequent to the investigation and target dates for completion of those actions.
I trust the information provides assurances to you that The Dudley Group NHS Foundation Trust has taken appropriate action to address the matters of concern raised.
Action Should Be Taken
1. Given the examples of poor record keeping, poor communication with the family and notification/escalation issues to a Doctor for examination. You may wish to consider reviewing your policy and/or additional training given to those involved.
Report Sections
Investigation and Inquest
On the 29 November 2017, I commenced an investigation into the death of Mr Ronald Compson. The investigation concluded at the end of the inquest on 18 January 2018. The conclusion of the inquest was a short narrative conclusion of accident.
The cause of death was:
1a Subdural Haematoma b Fall c
II Parkinsons Disease
The cause of death was:
1a Subdural Haematoma b Fall c
II Parkinsons Disease
Circumstances of the Death
i) Mr Compson had a medical history including Parkinsons disease and was admitted to Russells Hall Hospital on the 16 November 2017 after a period of confusion and drowsiness. ii) He was initially treated for sepsis and then later his medication for Parkinson's revised. iii) On the 18 November 2017 at 9.40pm he had an unwitnessed fall from a chair near his bed and sustained a head injury. Initially his neurological observations were within normal range. iv) There was a failure to notify a Doctor and no examination took place by a Doctor until the following morning at around 3.30am. At this stage he had vomited on two occasions and a CT scan was requested. v) His condition declined and he became unresponsive at around 7am and a CT scan revealed a subdural haematoma. vi) He wasn't deemed suitable for neurosurgery and placed on an end of life care pathway and sadly died on the 25 November 2017.
[IL1: PROTECT]
[IL1: PROTECT]
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.