Matthews Rogers
PFD Report
Historic (No Identified Response)
Ref: 2019-0448
Coroner's Concerns (AI summary)
Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5. It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department.
It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses.
The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing.
It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses.
The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing.
Sent To
- Blackpool Victoria Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
2 Mar 2020
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
On 27/11/2019 I commenced an investigation into the death of Matthew James Rogers. The investigation concluded at the end of the inquest on 10 December 2019. The inquest determined the medical cause of death was:
1(a) Multiple Organ Dysfunction 1(b) Pneumonia, multiple organ infarctions and ischaemic small and large bowel
II Methadone and cocaine, metastatic testicular cancer
The conclusion was Natural Causes.
1(a) Multiple Organ Dysfunction 1(b) Pneumonia, multiple organ infarctions and ischaemic small and large bowel
II Methadone and cocaine, metastatic testicular cancer
The conclusion was Natural Causes.
Circumstances of the Death
Mr Rogers was 31 years old when he was admitted to Blackpool Victoria Hospital on 10 July 2019. Mr Rogers had a previous history of testicular cancer with pulmonary metastases and reported to the Paramedics that he had been suffering from worsening pain for two days with weakness and lethargy. Mr Rogers was noted to be complaining of pain whilst breathing, he had poor peripheral perfusion and his hands were cold, swollen and discoloured.
Upon triage at 20:47 on 10 July 2019, Mr Rogers was noted to have a NEWS score of 1. By 03:30 on 11 July 2019, the NEWS score had risen to 6. The NEWS score then increased to 8 at 06.00 and thereafter to a score of 11. There was no record of any observations being taken between 03:30 and 06:00 despite the NEWS score having risen to 6 at 03:30.
During this time a plan was made for Mr Rogers to be transferred to the Emergency Room for closer monitoring and review by the Medical Registrar, however the Emergency Room was fully occupied and Mr Rogers was therefore transferred to a more viewable cubicle nearer to the nurse's station. The Medical Registrar was due to assess Mr Rogers on two occasions but on both occasions was called to other emergencies on the wards.
Following a Critical Care review, a plan was put in place to treat the low blood sugar of Mr Rogers with oral and IV glucose and further medication was given to correct the patient's electrolytes. A plan for Critical Care was made at 11:30. The patient was found to be in peri‐arrest and a 2222 Medical Emergency Call was placed to the Critical Care Team at 12:00 and they attended immediately.
Transfer was made to the Intensive Care Unit at 14:00 and a CT scan showed extensive organ injury including ischaemia of the liver, spleen and bowel. A DNACPR was completed at 16:20 by the Critical Care Consultant as, in critical illness, CPR was futile. The condition of Mr Rogers deteriorated and he died at Blackpool Victoria Hospital on 11 July 2019 at 22:18.
Upon triage at 20:47 on 10 July 2019, Mr Rogers was noted to have a NEWS score of 1. By 03:30 on 11 July 2019, the NEWS score had risen to 6. The NEWS score then increased to 8 at 06.00 and thereafter to a score of 11. There was no record of any observations being taken between 03:30 and 06:00 despite the NEWS score having risen to 6 at 03:30.
During this time a plan was made for Mr Rogers to be transferred to the Emergency Room for closer monitoring and review by the Medical Registrar, however the Emergency Room was fully occupied and Mr Rogers was therefore transferred to a more viewable cubicle nearer to the nurse's station. The Medical Registrar was due to assess Mr Rogers on two occasions but on both occasions was called to other emergencies on the wards.
Following a Critical Care review, a plan was put in place to treat the low blood sugar of Mr Rogers with oral and IV glucose and further medication was given to correct the patient's electrolytes. A plan for Critical Care was made at 11:30. The patient was found to be in peri‐arrest and a 2222 Medical Emergency Call was placed to the Critical Care Team at 12:00 and they attended immediately.
Transfer was made to the Intensive Care Unit at 14:00 and a CT scan showed extensive organ injury including ischaemia of the liver, spleen and bowel. A DNACPR was completed at 16:20 by the Critical Care Consultant as, in critical illness, CPR was futile. The condition of Mr Rogers deteriorated and he died at Blackpool Victoria Hospital on 11 July 2019 at 22:18.
Copies Sent To
next of kin of Mr Matthew James Rogers
I am also under a duty to send the Chief Coroner a copy of your response
Signature
Andrew Cousins Assistant Coroner Blackpool & Fylde
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.