Taejelle Francois
PFD Report
Historic (No Identified Response)
Ref: 2019-0297
Coroner's Concerns (AI summary)
A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.
View full coroner's concerns
(1) At the point of admission into the Accident and Emergency Department;, Taejelle was taken into the waiting area without either the Receptionist or the Triage nurse having the opportunity to visually assess despite Tae'jelle medically critical state. Tae'jelle was taken into the waiting area of reception; where she stopped breathing her, being
It was only as a result of the intervention of a member of the public that this condition was discovered, and as a result of that involvement Tae'jelle was taken into the Resus Department; where further treatment failed to revive her_ (2) Evidence was given at the Inquest as to a Guidance recommended by The Royal College of Emergency Medicine upon dealing with the Emergency Assessment of Emergency patients. Such a Protocol provides for Reception to inform the Triage nurse of suspected seriously unwell patient;, with the opportunity of then escalating the treatment of that patient: (3) Evidence was at the Inquest that this opportunity was missed as neither the receptionist nor the Triage Nurse were provided with the opportunity to make the necessary assessment, despite the fact that the Department was not at the time_
It was only as a result of the intervention of a member of the public that this condition was discovered, and as a result of that involvement Tae'jelle was taken into the Resus Department; where further treatment failed to revive her_ (2) Evidence was given at the Inquest as to a Guidance recommended by The Royal College of Emergency Medicine upon dealing with the Emergency Assessment of Emergency patients. Such a Protocol provides for Reception to inform the Triage nurse of suspected seriously unwell patient;, with the opportunity of then escalating the treatment of that patient: (3) Evidence was at the Inquest that this opportunity was missed as neither the receptionist nor the Triage Nurse were provided with the opportunity to make the necessary assessment, despite the fact that the Department was not at the time_
Sent To
- Calderdale and Huddersfield NHS Trust
- Chief Coroner
Response Status
Linked responses
0 of 2
56-Day Deadline
11 Nov 2019
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 21* November 2017 an investigation into the death of Tae jelle Kaliyah Francois was commenced: - The investigation concluded at the end of the inquest on 4 September 2019. The conclusion of the inquest was a Narrative Conclusion as set out below: Ia - The Medical Cause of Death was Acute Asthma
Circumstances of the Death
On the 3" June 2017 Taejelle Kaliyah Francois continued to suffer symptoms of an acute Asthma Attack which had begun several days previously: Despite the use of prescribed medicine her ill health continued and a decision was taken to seek hospital care by her family. During the journey to hospital and whilst waiting for admission Tae'jelle's condition deteriorated critically and she collapsed: Despite receiving appropriate resuscitation treatment she failed to respond and tragically passed away at Huddersfield Royal Infirmary at 22.45 hours that day:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.