Paul Reynolds
PFD Report
All Responded
Ref: 2020-0178
All 1 response received
· Deadline: 17 Nov 2020
Coroner's Concerns (AI summary)
Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.
View full coroner's concerns
A Root Cause Analysis by an Independent Anaesthetist found:- Root Cause There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic. The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient. Lessons Learned The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned. The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed. Recommendations
1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk.
2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available.
3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency.
1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk.
2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available.
3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency.
Responses
Action Taken
The trust confirms that all three recommendations regarding the availability of patient records and understanding of patient's underlying conditions have been fulfilled. (AI summary)
The trust confirms that all three recommendations regarding the availability of patient records and understanding of patient's underlying conditions have been fulfilled. (AI summary)
View full response
Dear Mr Arrow, Re: Paul Vincent Reynolds (dob. 22 September 1965) University Hospitals Plymouth Dr MBBS MRCP FRCP Medical Director and Cons. Radiologist Department of Clinical Management Level 07 University Hospitals Plymouth NHS Trust Derriford Road Crownhill Plymouth PL6 8DH Tel:
I write in response to the Regulation 28 report dated 21 st September, raising concerns regarding the unavailability of full patient records and incomplete appreciation and understanding of a patient's underlying medical condition. I can confirm that the three recommendations listed in the report have indeed been fulfilled. I hope the above serves to provide assurance around the actions we are taking in respect of the concerns that you have raised and that these will help prevent future deaths of this nature. Yotl?~:--~ Dr
Me,dical Director ?/ cc. , Legal Manager, University Hospitals Plymouth NHS Trust _/MINDFUL VEMPLOYER Working in partnership with the Peninsula Medical School Chairman:
Chief Executive:
I write in response to the Regulation 28 report dated 21 st September, raising concerns regarding the unavailability of full patient records and incomplete appreciation and understanding of a patient's underlying medical condition. I can confirm that the three recommendations listed in the report have indeed been fulfilled. I hope the above serves to provide assurance around the actions we are taking in respect of the concerns that you have raised and that these will help prevent future deaths of this nature. Yotl?~:--~ Dr
Me,dical Director ?/ cc. , Legal Manager, University Hospitals Plymouth NHS Trust _/MINDFUL VEMPLOYER Working in partnership with the Peninsula Medical School Chairman:
Chief Executive:
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2021-0151
Sent to: Brittania Jinky Jersey LimitedBrittania Hotels Group LimitedAll responded
This report (2020-0178) is shown above.
Sent To
- Derriford Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
17 Nov 2020
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
Report Sections
Investigation and Inquest
An Inquest into the death of Paul Vincent Reynolds (dob: 22 September 1965) was opened on 7 January 2020 and heard on 18 September 2020. The Coroner recorded the following NARRATIVE verdict The deceased suffered from learning difficulties and comorbidities which made him vulnerable. He presented to hospital with a swollen hand. One finger became necrotic and required amputation. A decision was made on initial information to carry out surgery on the finger under general anaesthetic. The Deceased's full hospital notes were not available and the deceased had limited discussion with medical staff. The incomplete appreciation and understanding of the patients underlying medical condition led to an inappropriate choice of monitoring and anaesthetic. The deceased suffered a loss of blood pressure and then had a hypoxic period following administration of general anaesthetic. He deteriorated and died from the hypoxic event on 31 December 2019 at Derriford Hospital.
Circumstances of the Death
The deceased suffered a hypoxic period following administration of a general anaesthetic.
Action Should Be Taken
Please confirm the recommendations of the Root Cause Analysis have been implemented.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.