Leslie Clewarth
PFD Report
All Responded
Ref: 2020-0229
All 1 response received
· Deadline: 15 Jan 2021
Response Status
Responses
1 of 1
56-Day Deadline
15 Jan 2021
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
In the circumstances it is my statutory duty to report to from day: being you:
(1) Without adequate records showing the care provided or dosage administered, was not possible to corroborate the testimony of nurses who had attended to Mr Clewarth on the afternoon he died: This fuelled the suspicions raised by his daughter and her husband: (2) Drugs which were left unused after Mr Clewarth's death were not accounted for. Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient's safety or health at risk.
(1) Without adequate records showing the care provided or dosage administered, was not possible to corroborate the testimony of nurses who had attended to Mr Clewarth on the afternoon he died: This fuelled the suspicions raised by his daughter and her husband: (2) Drugs which were left unused after Mr Clewarth's death were not accounted for. Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient's safety or health at risk.
Responses
Response received
View full response
Dear Mr McLoughlin
Re: Inquest touching the death of Leslie Clewarth (deceased)
I am responding on behalf of the Trust to the Regulation 28 Report to Prevent Future Deaths issued by yourself to The Mid Yorkshire Hospitals NHS Trust on 10th November
2020.
The Matters of Concern raised in your report were: -
1) Without adequate records showing the care provided or dosage administered, it was not possible to corroborate the testimony of nurses who had attended to Mr C on the afternoon he died. This fuelled the suspicions raised by his daughter and her husband.
2) Drugs which were left unused after Mr C’s death were not accounted for
Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient’s safety of health at risk.
I would like to thank you for bringing these matters to our attention. I absolutely agree that clear documentation is key to ensuring patient safety.
In order to respond to this Regulation 28 notice we have taken the opportunity to review our Trust Syringe Pump Policy, the Trust Syringe Pump combined prescription and administration chart and the relevant sections of our Trust Medicines Management Policy. In addition we have audited 10 cases from gate 34 where patients were having medication administered via a syringe pump that was subsequently discontinued at the end of their life against the syringe pump policy.
Your ref:
Our ref:
Date: 13 January 2021
Mr K McLoughlin Senior Coroner Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS
Medical Director Trust Headquarters and Medical Education Centre Aberford Road Wakefield WF1 4DG
PA:
In light of the above reviews we have determined that the syringe pump policy and the prescription / administration chart should be revised to provide clearer guidance and support better adherence to the policy. In particular this relates to the recording of any medication remaining in the syringe at each check and the amount discarded at the change or end of the use of the syringe driver and a prompt to support staff in recognising when the next syringe change will be required. Once the revised policies have gone through the appropriate governance routes in the Trust there will be further training delivered to support their use.
Once again thank you for bringing these matters to our attention.
Re: Inquest touching the death of Leslie Clewarth (deceased)
I am responding on behalf of the Trust to the Regulation 28 Report to Prevent Future Deaths issued by yourself to The Mid Yorkshire Hospitals NHS Trust on 10th November
2020.
The Matters of Concern raised in your report were: -
1) Without adequate records showing the care provided or dosage administered, it was not possible to corroborate the testimony of nurses who had attended to Mr C on the afternoon he died. This fuelled the suspicions raised by his daughter and her husband.
2) Drugs which were left unused after Mr C’s death were not accounted for
Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient’s safety of health at risk.
I would like to thank you for bringing these matters to our attention. I absolutely agree that clear documentation is key to ensuring patient safety.
In order to respond to this Regulation 28 notice we have taken the opportunity to review our Trust Syringe Pump Policy, the Trust Syringe Pump combined prescription and administration chart and the relevant sections of our Trust Medicines Management Policy. In addition we have audited 10 cases from gate 34 where patients were having medication administered via a syringe pump that was subsequently discontinued at the end of their life against the syringe pump policy.
Your ref:
Our ref:
Date: 13 January 2021
Mr K McLoughlin Senior Coroner Coroner’s Office and Court 71 Northgate Wakefield WF1 3BS
Medical Director Trust Headquarters and Medical Education Centre Aberford Road Wakefield WF1 4DG
PA:
In light of the above reviews we have determined that the syringe pump policy and the prescription / administration chart should be revised to provide clearer guidance and support better adherence to the policy. In particular this relates to the recording of any medication remaining in the syringe at each check and the amount discarded at the change or end of the use of the syringe driver and a prompt to support staff in recognising when the next syringe change will be required. Once the revised policies have gone through the appropriate governance routes in the Trust there will be further training delivered to support their use.
Once again thank you for bringing these matters to our attention.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action_
Report Sections
Investigation and Inquest
On 23/04/20 commenced an investigation into the death of Leslie Clewarth aged 86. The investigation concluded at the end of the Inquest on 06/11/20_ The Inquest reached a narrative conclusion to the effect that Leslie Clewarth died in hospital natural causes: Ia. aspiration pneumonia, 1b. small bowel obstruction Ic. adhesions within the peritoneal cavity and II. ischaemic heart disease
Circumstances of the Death
The family of Mr Clewarth were called before 7am on 07/04/20 due to the deterioration in his condition: They were permitted to remain at his bedside throughout the day, notwithstanding the COVID19 visiting restrictions then in force. Concerns were raised by his daughter and her husband in relation to: The NG tube previously inserted was no longer in place_ The syringe driver was empty at some point after 4pm that In consequence_ he was deprived of essential medication and hence died in agony after choking on faecal material aspirated_
3) After he had died an injection of Buscopan was made. He had not been treated for severe coronary condition despite in hospital for many weeks_ Medical records which should have documented these matters were missing Or inadequate.
3) After he had died an injection of Buscopan was made. He had not been treated for severe coronary condition despite in hospital for many weeks_ Medical records which should have documented these matters were missing Or inadequate.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.