Kay Sheard
PFD Report
Unknown
No published response · Over 2 years old
Response Status
Responses
0
56-Day Deadline
15 Feb 2016
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
During the procedure the Deceased's oxygen saturations were being monitored by a pulse oximeter for which was advised that the alarm settings are routinely set at 85% However all evidence indicated that it was not the actual level of reading which would be significant for a patient but rather the amount by which saturations had dropped from the patients normal base level. Notwithstanding this, the evidence indicated that this would not be taken into account when fixing an alarm setting level and am therefore concerned that there exists a potential risk to patients which could be reduced or eliminated by ensuring that the alarm level correctly reflects the individual patient's condition. Kay
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action.
Report Sections
Investigation and Inquest
On the 8th of January 2015 commenced an investigation into the death of Michelle Sheard (DOB 6.1.73,DOD 6.1.15). The investigation concluded at the end of the inquest on the 16th of December 2015. The cause of death was 1(a) Unascertained and recorded an Open Conclusion
Circumstances of the Death
The Circumstances of the death are that on the 6th of January 2015 the Deceased underwent an outpatient procedure under sedation at Glan Clwyd HGospital for the removal of gall stones form the bile duct: Upon completion of the procedure she went into cardiorespiratory failure for reasons which could not be established at a Post Mortem nor from evidence at the inquest,
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.