James Quinton
PFD Report
All Responded
Ref: 2018-0056
All 1 response received
· Deadline: 19 Apr 2018
Coroner's Concerns (AI summary)
Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
View full coroner's concerns
_ Coroner' $ Court and Office; Doncaster Crown Court; Road, Doncaster, DNI 3HS Tel 01302 737135 Fax 01302 736365 Ms drug pain, College
(1) During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants t0 get a clear picture of events that had been occurring: Clearly poor record keeping has significant implications for patients_ (2) Furthermore, the course of the resuscitation a decision was made for Mr Quinton to be given 4 mgs of Noradreneline This was to be given as an infusion. Unfortunately, this was actually given as a 4 mg iv bolus. Although the records suggest this did not have a detrimental effect on Mr Quinton (his blood pressure had been exceptionally low) this clearly could be highly significant for other patients_ It also raises the question of other patients given either the wrong or the wrong amount of drug or the wrong method of administration when the procedure for drugs to be prescribed in this scenario is on a verbal basis only: It would seem sensible to have some checking procedure by the person administering the checking with the person who had prescribed it to make sure their understanding is correct: From the evidence heard it seems there are no such procedures in place
(1) During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants t0 get a clear picture of events that had been occurring: Clearly poor record keeping has significant implications for patients_ (2) Furthermore, the course of the resuscitation a decision was made for Mr Quinton to be given 4 mgs of Noradreneline This was to be given as an infusion. Unfortunately, this was actually given as a 4 mg iv bolus. Although the records suggest this did not have a detrimental effect on Mr Quinton (his blood pressure had been exceptionally low) this clearly could be highly significant for other patients_ It also raises the question of other patients given either the wrong or the wrong amount of drug or the wrong method of administration when the procedure for drugs to be prescribed in this scenario is on a verbal basis only: It would seem sensible to have some checking procedure by the person administering the checking with the person who had prescribed it to make sure their understanding is correct: From the evidence heard it seems there are no such procedures in place
Responses
Action Planned
Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the issue of IV drug administration in emergencies during resuscitation. The clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status. (AI summary)
Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the issue of IV drug administration in emergencies during resuscitation. The clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status. (AI summary)
View full response
Dear Ms Mundy Re: James Robert Quinton (Deceased) DOB: 03.01.1975 ~ DOD: 14.03.2017 write in response to Regulation 28 Report 'Prevention of Future Deaths' dated 22 February 2018 sent to the Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and for which thank you: note your concerns as follows;
1. Poor quality nursing notes and lack of information on the observation chart making it difficult for reviewing consultants to clear picture of events that had been occurring: 2 In the course of resuscitation which was supposed to be given by infusion was given as a bolus raising the question of the wrong drug or the wrong amount of drug of the wrong method of administration occurring when drugs are prescribed in such scenario on a verbal basis only: have been assisted by Matron, Emergency Department (ED) and ED Governance Lead in constructing this response: get drug
would respond as follows;
1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department: The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the resuscitation. The Emergency Department is also in the process of obtaining a update of the software on the current monitors in order to allow automatic printing of the observations in the course of the procedure: am informed by that a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end f April to look at systems and processes for working together within the Resus area. understand that the IV Administration has also been sent to all qualified staff in the emergency department,
3. Matron Sidwell has also advised me that the clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status take this opportunity to enclose for your awareness the relevant policies which are available on the Trust Intranet Safe and Secure Handling of Medicines PATIMMIa Safe and Secure Handling of Medicines Policy Controlled Drugs PAT/MMIb Injectable Medicines Policy PAT/MMS trust that the contents of this letter will reassure you that the Trust has taken steps to minimise the risk of a recurrence of the events outlined in the PFDR document Please do not hesitate to revert back to me should you feel that there are any outstanding issues.
1. Poor quality nursing notes and lack of information on the observation chart making it difficult for reviewing consultants to clear picture of events that had been occurring: 2 In the course of resuscitation which was supposed to be given by infusion was given as a bolus raising the question of the wrong drug or the wrong amount of drug of the wrong method of administration occurring when drugs are prescribed in such scenario on a verbal basis only: have been assisted by Matron, Emergency Department (ED) and ED Governance Lead in constructing this response: get drug
would respond as follows;
1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department: The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the resuscitation. The Emergency Department is also in the process of obtaining a update of the software on the current monitors in order to allow automatic printing of the observations in the course of the procedure: am informed by that a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end f April to look at systems and processes for working together within the Resus area. understand that the IV Administration has also been sent to all qualified staff in the emergency department,
3. Matron Sidwell has also advised me that the clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status take this opportunity to enclose for your awareness the relevant policies which are available on the Trust Intranet Safe and Secure Handling of Medicines PATIMMIa Safe and Secure Handling of Medicines Policy Controlled Drugs PAT/MMIb Injectable Medicines Policy PAT/MMS trust that the contents of this letter will reassure you that the Trust has taken steps to minimise the risk of a recurrence of the events outlined in the PFDR document Please do not hesitate to revert back to me should you feel that there are any outstanding issues.
Sent To
- Doncaster Royal Infirmary
Response Status
Linked responses
1 of 1
56-Day Deadline
19 Apr 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
On 25/03/2017 commenced an investigation into the death of James Robert Quinton, 42 The investigation concluded at the end of the inquest on 30 January 2018. The conclusion of the inquest was a Narrative conclusion: James Robert Quinton collapsed on 14 March 2017 due to a combination of a ruptured spleen and methadone and heroin ingestion. Mr Quinton failed to respond to extensive resuscitation and supportive measures and he died in the Doncaster Royal Infirmary later that day: The cause of death was 1a. Splenic rupture and combined morphine and methadone toxicity Rivoroxaban therapy
Circumstances of the Death
James Quinton had a known history of chronic and alcohol abuse. His partner had been in a relationship with him for 12 years and has no knowledge of him having ever had any employment: He had a medical history of alcoholic liver disease, intravenous drug misuse, hepatitis C , epilepsy, previous DVT , on rivaroxaban, schizophrenia. He was admitted to DRI A&E at 02.30 hrs with a presenting history of week vomiting blood, day abdominal He had been found unresponsive on the bathroom floor collapsed. On admission he was unresponsive Investigations commenced -Bloods were taken INR 3 given vitamin K to reverse. Acidotic PH6.8, lactate greater than 20. 03.15 hrs cardiac arrest arrest call
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you Dr Sewa Singh have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.