Hubert Kelly
PFD Report
Partially Responded
Coroner's Concerns (AI summary)
Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
View full coroner's concerns
1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
Responses
Sent To
- Care Quality Commission
- The Dudley Group Trust Foundation Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
14 Nov 2018
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 21st March 2018, I commenced an investigation into the death Hubert Kelly. The investigation concluded at the end of the inquest on 12 September 2018. The conclusion of the inquest was a short narrative conclusion of natural causes death.
The cause of death was:
1a Old Age 2 Hypertension, Aortic Stenosis, Bullous Pemphigoid
The cause of death was:
1a Old Age 2 Hypertension, Aortic Stenosis, Bullous Pemphigoid
Circumstances of the Death
i) On the evening of 13th November 2017 Hubert Kelly was taken to hospital in an ambulance following a deterioration in his health; ii) He was triaged by a nurse at the Accident and Emergency Department at Russells Hall Hospital; iii) He was directed to the waiting area of the emergency department where he spent four hours in a wheelchair sat with his family; iv) There was no meaningful interaction with Mr Kelly during those hours with nursing staff until it was noticed that he was not disrupted by noise in the waiting room. Nursing staff conducted a check at 4am and discovered that Mr Kelly had passed away.
Action Should Be Taken
1. The Trust may wish to review the accountability and monitoring in place for patients who have been triaged in the Emergency Department and are awaiting further clinical assessment.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.