Peter Knight

PFD Report All Responded Ref: 2019-0219
Date of Report 18 March 2019
Coroner Jacqueline Lake
Coroner Area Norfolk
Response Deadline est. 9 September 2019
Hospital Death (Clinical Procedures and medical management) related deaths
Judiciary.uk Report PDF
All 1 response received · Deadline: 9 Sep 2019
Coroner's Concerns (AI summary)
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.
View full coroner's concerns
At the inquest was satisfied that the Trust took the concerns raised seriously and was in the process of reviewing its Policy with regard to the transfer of patients, particularly those who are oxygen dependant: It was anticipated the Policy would be completed by the end of February 2019. In the circumstances, wrote to the Trust asking them to write to me by 15 March 2019 with full details of the Policy: Not having heard from the Trust, my Officer contacted the Trust today: A response has been received indicating that new documentation has now been generated but a trial into its use has not yet commenced. Although it is stated that a trial is due to be started within the week and that if effective, implementation will be ratified by end of April; am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest and its trial has not yet commenced:
Responses
The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust NHS / Health Body
8 May 2019
Action Taken
The Trust revised its Transfer of Patients Policy, ratified on May 7th, and delivered "Transferring the Critically Ill Patient" training including a decision to not transfer patients on Hi Flo airvo2 without battery backup. They also redesigned transfer stickers using an SBAR format. (AI summary)
View full response
Dear Mrs Lake Regulation 28 in the matter of Mr Peter Knight (deceased) "m writing to say that am now able to respond to your Regulation 28 report dated 18 March with respect to the Transfer of Patients Policy. In order to do this attach a timeline of the events which have taken place since Mr Knight's sad death and a copy of the policy itself which was ratified at the Clinical Governance Committee meeting on 7th May: can also advise that have visited the Knight family to apologise for the care and subsequent death of Mr Knight and for the way the family was treated It was totally unacceptable. have asked Jand the family to attend our next Board meeting to share their experience if they feel they can do so. We have also promised to keep in close touch with the family throughout this difficult time hope that this reply gives you some level of assurance of the seriousness the Trust has applied and the learning needed in going forward.
Sent To
  • Queen Elizabeth Hospital ›The Queen Elizabeth Hospital
Response Status
Linked responses 1 of 1
56-Day Deadline 9 Sep 2019
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
On 19/06/2018 commenced an investigation into the death of Peter David KNIGHT aged 70. The investigation concluded at the end of the inquest on 15/01/2019. The conclusion of the inquest was; Accident; The medical cause of death was: 1a Acute Exacerbation of Idiopathic Pulmonary Fibrosis 1b 1c Il Ischaemic Heart Disease
Circumstances of the Death
Mr Knight had a long-standing history of idiopathic pulmonary fibrosis and was oxvgen dependent: He was admitted to the Queen Elizabeth Hospital on 5 June 2018 and was diagnosed with a chest infection. On 6 June 2018 Mr Knight was transferred from the Medical Assessment Unit to Necton Ward during which time he was not connected to portable cylinder oxygen: On arrival on the he was seen to be hypoxic and despite being given oxygen, Mr Knight died later that evening:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.