Mary Johnson
PFD Report
All Responded
Ref: 2019-0495-wp26975
All 1 response received
· Deadline: 29 Mar 2019
Coroner's Concerns (AI summary)
Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
View full coroner's concerns
In the circumstances it is my statutory to report to you: [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant's instructions regarding provision of medication prior to operation (2) It was suggested that the availability of porters determined ability of the hospital theatres to out operations Town Hall, St Owen Street; Hereford, HRI 2PJ Tel 01432 261813 Fax 01432 261720 the Mrs Mary duty the the carry
Responses
Action Taken
• The use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld, has been relaunched and clarified to all pertinent staff. • All speciality specific thromboprophylaxis guidelines are being reviewed. (AI summary)
• The use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld, has been relaunched and clarified to all pertinent staff. • All speciality specific thromboprophylaxis guidelines are being reviewed. (AI summary)
View full response
Dear We stay Tues July
Although not actually the root cause for this patient's death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld. In addition to and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and would be happy to update you on the progress of this a later date_ trust this answers all the outstanding questions you have for this sad case but would be more than happy to meet with you in person to clarify any other details. Best wishes
Although not actually the root cause for this patient's death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld. In addition to and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and would be happy to update you on the progress of this a later date_ trust this answers all the outstanding questions you have for this sad case but would be more than happy to meet with you in person to clarify any other details. Best wishes
Sent To
- Wye Valley NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Mar 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 the Ist day of August 2018 commenced an investigation into death of Mary Bertha Johnson
Circumstances of the Death
Bertha Johnson died on the 25th July 2018 at the County Hospital, Hereford, Mrs Johnson had fallen on the 2Oth July 2018 causing a periprosthetic fracture of the femur:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Transfusion Committees and Tranexamic Acid - England
Infected Blood Inquiry
Inadequate Pre-Operative Risk Assessment
Tranexamic Acid - Scotland, Wales and NI
Infected Blood Inquiry
Inadequate Pre-Operative Risk Assessment
Increase driver briefing frequency with safety as primary agenda item
Ladbroke Grove Inquiry
Staff rota communication
Establish and apply criteria for signallers exceeding maximum 72-hour work week
Ladbroke Grove Inquiry
Staff rota communication
Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Bristol Heart Inquiry
Inadequate Pre-Operative Risk Assessment
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.