Lesley Brass
PFD Report
Historic (No Identified Response)
Ref: 2020-0113
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
23 Jul 2020
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 AI summary
The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Report Sections
Investigation and Inquest
On 30"h October 2018 an investigation commenced into the death of Julie BRASS,
58. The investigation concluded at the end of the inquest on 2nd March 2020. The medical cause of death was: 1a) Cardiac arrhythmia 1b) Hyperkalaemia (untreated) Ic) Infected scalp laceration (treated), diabetes mellitus, pneumonia
2) Ischaemic heart disease The narrative conclusion of the inquest was: Mrs Brass was an inpatient on the Plastic Surgery ward at Southmead Hospital when she developed severe hyperkalaemia, a condition requiring emergency treatment_ The Hospital'$ own internal procedures required that severe hyperkalaemia must be treated within 30 minutes, and the relevant staff looking after her were aware that she faced a life threatening emergency, but the window for effective treatment expired without the required treatment being given, as a result Mrs Brass went into cardiac arrest and sadly died. Her death was contributed to by neglect:
58. The investigation concluded at the end of the inquest on 2nd March 2020. The medical cause of death was: 1a) Cardiac arrhythmia 1b) Hyperkalaemia (untreated) Ic) Infected scalp laceration (treated), diabetes mellitus, pneumonia
2) Ischaemic heart disease The narrative conclusion of the inquest was: Mrs Brass was an inpatient on the Plastic Surgery ward at Southmead Hospital when she developed severe hyperkalaemia, a condition requiring emergency treatment_ The Hospital'$ own internal procedures required that severe hyperkalaemia must be treated within 30 minutes, and the relevant staff looking after her were aware that she faced a life threatening emergency, but the window for effective treatment expired without the required treatment being given, as a result Mrs Brass went into cardiac arrest and sadly died. Her death was contributed to by neglect:
Circumstances of the Death
As above, the circumstances of the death were that: Mrs BRASS had a number of co-morbidities, including diabetes, high cholesterol, high blood pressure; and severe peripheral neuropathy She fell at home on 13 October 2018,sustaining a head injury_ Telephone 01275 461920 Email AvonCoronersTeam@bristol gcsX gov.uk Website Www avon-coroner.com Avon Lesley aged and
Her head wound subsequently became infected, she was admitted to Southmead Hospital by ambulance on 19 October 2018 On 20 October 2018 she was transferred to Gate 334 (the Plastic Surgery ward) While she was an inpatient on the Plastics ward Mrs BRASS's kidneys were under additional strain (as a result of her wound infection) and she began to experience hyperkalaemia (high potassium levels in her blood) A blood sample was taken from Mrs BRASS at 10.30am on 22 October 2018,and subsequently analysed at the hospital laboratory When the sample was analysed Mrs BRASS's potassium level was 7.1, a reading which indicates "severe hyperkalaemia" Severe hyperkalaemia is a medical emergency, and should be treated within 30 minutes of the condition recognised Untreated, it carries a very high risk of cardiac problems which can be fatal The Trust which runs Southmead Hospital, recognising the risk posed by hyperkalaemia, has produced Standard Operating Procedure ("SOP") to indicate how the condition should be dealt with That SOP states that severe hyperkalaemia (defined as a potassium level of 6.5 or above) is "potentially life threatening" and "needs emergency treatment" The SOP mandates that a patient with severe hyperkalaemia must be given intravenous calcium (either 1Oml of 10% Calcium Chloride or 3Oml of 10% Calcium Gluconate) within 15-30 minutes of the condition being recognised Shortly before 12.3Opm on 22 October 2018 the laboratory phoned Mrs BRASS'$ potassium reading (of 7.1) through to the Plastics ward The call was taken by a member of the Hospital's nursing staff, who discussed the alarmingly high potassium result with a number of other members of nursing staff on the ward Once the Plastics ward had been notified of that potassium result; the team who were looking after Mrs BRASS had a clear duty (under the Trust'$ own SOP) to ensure that she received IV calcium within 30 minutes In order for that treatment to be administered, Mrs BRASS had to be seen by a doctor: three members of the nursing staff gave evidence to the effect that they knew that Mrs BRASS was experiencing a life threatening medical emergency (therefore they must have understood the importance of making sure she was seen by a doctor) The nursing staff made various attempts to get a doctor to come and see Mrs BRASS, but these were completely ineffective Not only did Mrs BRASS not receive the IV calcium that she required within 15-30 minutes (as required by the Trust'$ own SOP); but she was not even seen by a doctor in that time She was subsequently taken off-ward for an ultrasound scan: Mrs BRASS was booked into the radiology ward at 1.13pm,and went into a fatal cardiac arrest at 1.22pm on 22 October 2018 By the time that Mrs BRASS went into cardiac arrest almost an hour had passed since the Plastics ward had been notified of her severe hyperkalaemia, and she still had not been seen by a doctor, much less received the required medication There was clear (uncontested) evidence that if she had been treated in line with the Trust's SOP she would probably have survived There was no doubt whatsoever in my mind that Mrs BRASS's death was contributed to by neglect:
Her head wound subsequently became infected, she was admitted to Southmead Hospital by ambulance on 19 October 2018 On 20 October 2018 she was transferred to Gate 334 (the Plastic Surgery ward) While she was an inpatient on the Plastics ward Mrs BRASS's kidneys were under additional strain (as a result of her wound infection) and she began to experience hyperkalaemia (high potassium levels in her blood) A blood sample was taken from Mrs BRASS at 10.30am on 22 October 2018,and subsequently analysed at the hospital laboratory When the sample was analysed Mrs BRASS's potassium level was 7.1, a reading which indicates "severe hyperkalaemia" Severe hyperkalaemia is a medical emergency, and should be treated within 30 minutes of the condition recognised Untreated, it carries a very high risk of cardiac problems which can be fatal The Trust which runs Southmead Hospital, recognising the risk posed by hyperkalaemia, has produced Standard Operating Procedure ("SOP") to indicate how the condition should be dealt with That SOP states that severe hyperkalaemia (defined as a potassium level of 6.5 or above) is "potentially life threatening" and "needs emergency treatment" The SOP mandates that a patient with severe hyperkalaemia must be given intravenous calcium (either 1Oml of 10% Calcium Chloride or 3Oml of 10% Calcium Gluconate) within 15-30 minutes of the condition being recognised Shortly before 12.3Opm on 22 October 2018 the laboratory phoned Mrs BRASS'$ potassium reading (of 7.1) through to the Plastics ward The call was taken by a member of the Hospital's nursing staff, who discussed the alarmingly high potassium result with a number of other members of nursing staff on the ward Once the Plastics ward had been notified of that potassium result; the team who were looking after Mrs BRASS had a clear duty (under the Trust'$ own SOP) to ensure that she received IV calcium within 30 minutes In order for that treatment to be administered, Mrs BRASS had to be seen by a doctor: three members of the nursing staff gave evidence to the effect that they knew that Mrs BRASS was experiencing a life threatening medical emergency (therefore they must have understood the importance of making sure she was seen by a doctor) The nursing staff made various attempts to get a doctor to come and see Mrs BRASS, but these were completely ineffective Not only did Mrs BRASS not receive the IV calcium that she required within 15-30 minutes (as required by the Trust'$ own SOP); but she was not even seen by a doctor in that time She was subsequently taken off-ward for an ultrasound scan: Mrs BRASS was booked into the radiology ward at 1.13pm,and went into a fatal cardiac arrest at 1.22pm on 22 October 2018 By the time that Mrs BRASS went into cardiac arrest almost an hour had passed since the Plastics ward had been notified of her severe hyperkalaemia, and she still had not been seen by a doctor, much less received the required medication There was clear (uncontested) evidence that if she had been treated in line with the Trust's SOP she would probably have survived There was no doubt whatsoever in my mind that Mrs BRASS's death was contributed to by neglect:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.