Suzanne Roberts
PFD Report
Historic (No Identified Response)
Ref: 2019-0441
Coroner's Concerns (AI summary)
The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.
View full coroner's concerns
A Senior Consultant at the RSCH gave evidence at the Inquest In December 2019 and described the current system of managing patient records at the RSCH as "sub-optimal" and "flawed" and that a similar death to that of Suzanne Roberts could occur (in the same circumstance as seen In October 2015) In December 2019 The Jury found the management of patient records at the RSCH to be Ineffective, as was cross Department communication In relation to patient treatment The Jury also found ineffective communication and ineffective use of patient records within the Department of Trauma and Orthopaedics In relation to patient treatment Whilst there was evidence that E3Om had been recently spent by the Brighton and Sussex Universities Hopsital NHS Trust on a failed attempt to create a single electronic patient record, the Inquest revealed that There were at least three software systems In use by different Departments at RSCH, alongside paper records_ and that a portal system, Panda, was also partially In place In the absence of mandatory rules for the use of those systems or portal, and mandatory quality assurance about data uploaded to those systems or portal, there IS a continuing risk of future deaths due to Ineffective management of patient records and ineffective communication across departments at RSCH
Sent To
- NHS England
Response Status
Linked responses
0 of 1
56-Day Deadline
12 Feb 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
A seven day Article 2 Jury Inquest was completed on 12th December 2019 into the death of Suzanne Roberts
Circumstances of the Death
Miss Roberts was detained as patient under the Mental Health Act; at Dene, private hospital in West Sussex She died on 18"h October 2015 at the Dene; from sudden cardiac arrest arising out of Acute Kidney Injury, Pyelonephritis Chronic Dehyrdation and an underlying condition of a High Output Stoma Miss Roberts had significant physical healthcare Issues arising from her High Output Stoma; which together with other self-harming behaviours, resulted In her admission to the Royal Sussex County Hospital RSCH") In Brighton, East Sussex, on several occasions during her seven week stay at The Dene Her last admission to the RSCH was on 12th October 2015, where she was found to have high potassium and Acute Kidney Injury Due to systems and communications fallings between different Departments at the RSCH and within the Department of Trauma and Orthopaedics, Miss Roberts was discharged on 14h October 2015, without knowledge of her Initial admission, renal assessment and recommended in-patient treatment; but with blood test results that showed high levels of potassium; which ied to heart failure and death on 18'h October 2015 Jury found that there had been neglect The Jury made factual findings a) That there was fragmented information sharing between Departments at the RSCH, resulting In a serious failure to be aware of this patients needs b) There was not an effective system In place at the RSCH for the use of this patient's clinical records c) There was not an effective system In place at the Truama and Orthopaedic Department at the RSCH for ths use of this patient's clinical records d) There was not effective communication between all Departments at the RSCH and within the Department of Trauma and Orthopaedics at the RSCH relating to treatment of Suzanne Roberts And that these probably contributed and caused her death on 18'h October 2015 used The The
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action
Copies Sent To
Date 18th December 2019 Bubecp
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.