Hayley Clark
PFD Report
All Responded
Ref: 2016-0143
All 1 response received
· Deadline: 7 Jun 2016
Response Status
Responses
1 of 1
56-Day Deadline
7 Jun 2016
All responses received
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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 to report to you: Coroner'$ Court and Office, Doncaster Crown Court; Road, Doncaster, DNI 3HS Tel 01302 737135 Fax 01302 736365 The May long May duty College.
(1) There was a failure on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark's extremely low body weight.
(1) There was a failure on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark's extremely low body weight.
Responses
Response received
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Dear Mr Beresford
RE: Ms Hayley Clark – Regulation 28
Firstly, I wish to state on behalf of The Rotherham NHS Foundation Trust, how sorry we are for the shortcomings in practice relating to Ms Clark’s care. We have taken the learning from our investigation and your concerns seriously in order to improve practice and take action to ensure that other patients do not have the same experience in future.
Turning to the specific issues that you identified in your conclusion at the inquest on the 12th of April 2016:
“There was a failure, on the part of the staff who prescribed and administered the paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight”
I attach a copy of our additional action plan and can confirm that I am assured that the Patient Safety Group will oversee completion of the action plan. In the meantime please do not hesitate to contact me if you require any further information
RE: Ms Hayley Clark – Regulation 28
Firstly, I wish to state on behalf of The Rotherham NHS Foundation Trust, how sorry we are for the shortcomings in practice relating to Ms Clark’s care. We have taken the learning from our investigation and your concerns seriously in order to improve practice and take action to ensure that other patients do not have the same experience in future.
Turning to the specific issues that you identified in your conclusion at the inquest on the 12th of April 2016:
“There was a failure, on the part of the staff who prescribed and administered the paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight”
I attach a copy of our additional action plan and can confirm that I am assured that the Patient Safety Group will oversee completion of the action plan. In the meantime please do not hesitate to contact me if you require any further information
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you Ms Louise Barnett; Chief Executive, have the power to take such action.
Report Sections
Investigation and Inquest
On 27/05/2015 commenced an investigation into the death of Hayley Christine Clark, 36. The investigation concluded at the end of the inquest on 12 April 2016 conclusion of the inquest was a Narrative conclusion as follows: Hayley Christine Clark died, at Rotherham Hospital, on 24th 2015,from the effects of severe malnutrition. Her malnutrition arose from a combination of factors, which did not include anorexia, but which did include poor eating discipline due, in part, to longstanding abdominal discomfort_ The cause of death was 1a. Respiratory failure; 1b Pulmonary oedema, Ic Severe multi-iactorial malnutrition; Acute pyelonephritis, electrolyte imbalance, anaemia and immune deficiency
Circumstances of the Death
Hayley Christine Clark was a 36 years old female with a medical background which included term malnutrition , hypogammaglobulinemia, irritable bowel syndrome_ anaemia and depression She was admitted to Rotherham General Hospital on 12"h May 2015 with electrolyte imbalance. As part of a standard package of pain management; Ms Clark received Paracetamol, However the dose administered was the standard adult one and had not been adjusted to reflect Ms Clark's extremely low (less than 50kg) body weight. This overdose of Paracetamol caused derangement of Ms Clark's liver function. The problem was identified, the Paracetamol was withdrawn and Parvolex was administered. Ms Clark's condition deteriorated. She was transferred to the High Dependency Unit on 22nd 2015 and she died on 24th May 2015. The cause of her death was as set out above_
Inquest Conclusion
Hayley Christine Clark died, at Rotherham Hospital, on 24th 2015,from the effects of severe malnutrition. Her malnutrition arose from a combination of factors, which did not include anorexia, but which did include poor eating discipline due, in part, to longstanding abdominal discomfort_ The cause of death was 1a. Respiratory failure; 1b Pulmonary oedema, Ic Severe multi-iactorial malnutrition; Acute pyelonephritis, electrolyte imbalance, anaemia and immune deficiency
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.