Stephen Taylor
PFD Report
All Responded
All 1 response received
· Deadline: 27 Dec 2018
Coroner's Concerns (AI summary)
Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
View full coroner's concerns
Curing tne course of tha inquest the ewidence revealed matcr? givinig ESE lo corcern In m} cpinion there is a risk tnat future deains accur Urless action I5 laken Inthe circumstances it is my Btatutcry Culy t3 rpon [o YDu the hia He will
The MATTERS QF CONCERN ar0 a5 Icllows {1} heard U eviderca #rom Mr Young, the Tnusts Clinical Director wno had carred cula Rool Cause Analysis heard also irom one of Trusr8 consultanineurosurgeons Both corsuliants expressed their balief that neurosurgical palionts 0l Ihis nalure requlred additional support ircm their ccnzuttant phys clan collaagues was Iold Inat this has been an issue fOr 3cM0 time and remained unresolved In parcular, Inere was concern ihat a junior neurosurgical doctor w3s left to implementan a cohol wlthurawal regMen Was tald that these difficulties are nct confined t0 patients who are admllled with alcchol-ralated iesues bui extend acro35 whcle range cfneurosurgical patlents who require madical input (21 was told thal the alcanol wilhdrawal protocol was difficult to uriderstand This resuiled In Ihe doclor prescribirg diazepam wnen L orazapam should ceen Used, was Icld and shown an acton plan that the Trust intend: t0 implement lo Improve Ihe pocess
The MATTERS QF CONCERN ar0 a5 Icllows {1} heard U eviderca #rom Mr Young, the Tnusts Clinical Director wno had carred cula Rool Cause Analysis heard also irom one of Trusr8 consultanineurosurgeons Both corsuliants expressed their balief that neurosurgical palionts 0l Ihis nalure requlred additional support ircm their ccnzuttant phys clan collaagues was Iold Inat this has been an issue fOr 3cM0 time and remained unresolved In parcular, Inere was concern ihat a junior neurosurgical doctor w3s left to implementan a cohol wlthurawal regMen Was tald that these difficulties are nct confined t0 patients who are admllled with alcchol-ralated iesues bui extend acro35 whcle range cfneurosurgical patlents who require madical input (21 was told thal the alcanol wilhdrawal protocol was difficult to uriderstand This resuiled In Ihe doclor prescribirg diazepam wnen L orazapam should ceen Used, was Icld and shown an acton plan that the Trust intend: t0 implement lo Improve Ihe pocess
Responses
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2026-0020
Sent to: Kent and Medway Mental Health TrustVita health Group : Kent and Medway Talking TherapiesAll responded
This report (None) is shown above.
Sent To
- University Hospital Coventry and Warwickshire NHS TRUST
Response Status
Linked responses
1 of 1
56-Day Deadline
27 Dec 2018
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
In August 2018 an inquest wa8 opened into dealh cl Mr Taylor Wno died on 31 July 2018 The inqucst concluded at a heanng on 31 Oclober 2018 whera it wJ3 found that Mr Taylar had dled a5 tha resuli Dfan accident The causa of death given &t inquest "as Jajsepsis; ibj chest infection; 1c) nead Injury I) chraric obstructive pulmonary disease
Circumstances of the Death
Or 27 July ZD18 Mr Taylor suffered a fall at his hcme eddress wnd strjck his head, He was taken to the Alexandra Hospital where a CT cf hia head revealed a large azute haematoma After manzgement cf concition and 2 lurkei CT scan he was transferred to your Trust in the eaily hours 0f 28 July 2018 Following nis admisslon It was roted Inat Mr Taylor displayed signa of agtation ond tremors selzures. Il was falt Inat this wias likely to be related to alcchol withdrawal The dacior revicwed thz Trusts protocol tne management ofsuch patients and,In ercl, Frescnbed and acmiristerad Diazepam Cn 29 July ?018 Mr Taylor guffered 3 respiratory arrest was gwen an anlagonist and rerovered promptly to hiz pre-arrest condilion Sadly Mr Tay%t developed a chest infection &nd,despite treatment subsequenlly Gelarioraled and cied in the Trubt on 31 July: One of tho matters inwoslgaled altte inquest was whetner 35 8 Conbequence of Ine respiratory arresl Mr Taylor had aspialad 45 amatter of fact t wJz found tnal tho aspiralon had occuirad at Iha bme Df the triginal fall,
Action Should Be Taken
In my opinian acuon should be Iaken to prevent future deaths and believe you havo Ihe powa: to lake such acton would ba grateful ii You would review' whethor there is adequate sunport for neurosurgical patients "hj alsc have medical co-mcrblolties If ihere i5 rct, would be gratejul if you would consider how Ihal situation may best be adressed
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Use of information about compliance by regulator from: Media
Mid Staffs Inquiry
Patient safety governance
Clinical negligence harms learning
NHS Litigation Authority Improvement of risk management
Mid Staffs Inquiry
Patient safety governance
Clinical negligence harms learning
NHS Litigation Authority Improvement of risk management
Mid Staffs Inquiry
Patient safety governance
Clinical negligence harms learning
NHS Litigation Authority Improvement of risk management
Mid Staffs Inquiry
Patient safety governance
Clinical negligence harms learning
Evidence-based assessment
Mid Staffs Inquiry
Patient safety governance
Clinical negligence harms learning
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.