Howard Winter
PFD Report
All Responded
Ref: 2018-0040
All 1 response received
· Deadline: 2 Aug 2018
Coroner's Concerns (AI summary)
An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine fracture.
View full coroner's concerns
When Mr Winter attended at A & E on 23 & 26.8.17, he was diagnosed with a subdural haematoma following a CT scan head. It was not until after a CT scan of his spine was undertaken on 11.9.17 that he was diagnosed with a cervical spine fracture. The question arose as to whether; & following his initial presentation on 23.9.17 & admission on 26.8.17 there was any evidence of symptoms of neck pain which could have given rise to earlier investigations into, & possible earlier diagnosis of the cervical spine fracture. Igave evidence at the Inquest that on the 26.8.17 an auxiliary nurse had Tecorded in the nursing notes 'pain in necklback ~ unable to score There was no evidence written or othenwise_to demonstrate an escalation of this finding_to a doctor the for re-assessment; investigation & diagnosis levidence to Inquest was that this ought to have occurred Whilst this apparent absence of escalation may not necessarily have affected outcome for Mr Winter; were it to be repeated nOw, or in the future; the outcome for the patient involved could be potentially causative oflcontribute towards deathladverse outcome;
Responses
Action Taken
Cwm Taf University Health Board has undertaken two audits of NEWS scores, identified the need for further education and training, and is monitoring improvement work via the quarterly quality report. (AI summary)
Cwm Taf University Health Board has undertaken two audits of NEWS scores, identified the need for further education and training, and is monitoring improvement work via the quarterly quality report. (AI summary)
View full response
Dear Mr Barkley RE: Regulation 28 for Howard Winter Thank you for the correspondance in relation to the above Regulation 28 received on February 2018, which was also sent to the Health Board CEO Mrs Allison Williams Please note that I have discussed the content of your letter with both the CEO and the Director of Nursing: In relation to improvement work being undertaken within Cwm Taf University Health Board regarding NEWS wish to assure you that the following work has taken place:
1. Two audits have been undertaken across the Health Board to measure how the NEWS scores are completed and escalated. 2 We have a University Health Board Clinical Lead for the RRAILS (Rapid Response to Acute illness Learning Set) who is a Consultant Anaesthetist ad also the National Lead overseeing this important piece of work The audit has identified the need for further education and training as well as raising awareness amongst nursing and medical staff in relation to accurate documentation and escalation: The audit has also identified priority clinical areas for improvement work which will be progressed. Monitoring of the improvement work is undertaken via the quarterly quality report to the Quality & Risk Safety Committee: hope that I have provided assurance to you that your concerns are being dealt with in the University Health Board as part of our ongoing Quality Delivery Plan. RECEIED LU MAR 2018 Kind Regards Return Address: Cwm Taf University Health Board, Headquarters, Navigatioh Park,Abercynon; CF45 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Taf Universlty Health Board Is the operational name of the Cwm Taf Unlverslty Health Board/Bwrdd lechyd Prifysgol Cwm Taf Yw enw gwelthredol Bwrdd lechyd Prlfysgol Cwm Taf 14th
Vamal Mr Kamal Asaad Medical Director Cwm Taf University Health Board Cc: Mrs Allison Williams, CEO, Cwm Taf UHB Mrs Lynda Williams, Director of Nursing & Midwifery Services, Cwm Taf UHB
Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park; Abercynon, CF45 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Taf Universlty Health Board Is the operational name of the Cwm Taf Unlverslty Health Board/Bwrdd lechyd Prifysgol Cwm Taf Yw enw gwelthredol Bwrdd lechyd Prifysgol Cwm Taf Ascad
1. Two audits have been undertaken across the Health Board to measure how the NEWS scores are completed and escalated. 2 We have a University Health Board Clinical Lead for the RRAILS (Rapid Response to Acute illness Learning Set) who is a Consultant Anaesthetist ad also the National Lead overseeing this important piece of work The audit has identified the need for further education and training as well as raising awareness amongst nursing and medical staff in relation to accurate documentation and escalation: The audit has also identified priority clinical areas for improvement work which will be progressed. Monitoring of the improvement work is undertaken via the quarterly quality report to the Quality & Risk Safety Committee: hope that I have provided assurance to you that your concerns are being dealt with in the University Health Board as part of our ongoing Quality Delivery Plan. RECEIED LU MAR 2018 Kind Regards Return Address: Cwm Taf University Health Board, Headquarters, Navigatioh Park,Abercynon; CF45 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Taf Universlty Health Board Is the operational name of the Cwm Taf Unlverslty Health Board/Bwrdd lechyd Prifysgol Cwm Taf Yw enw gwelthredol Bwrdd lechyd Prlfysgol Cwm Taf 14th
Vamal Mr Kamal Asaad Medical Director Cwm Taf University Health Board Cc: Mrs Allison Williams, CEO, Cwm Taf UHB Mrs Lynda Williams, Director of Nursing & Midwifery Services, Cwm Taf UHB
Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park; Abercynon, CF45 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Taf Universlty Health Board Is the operational name of the Cwm Taf Unlverslty Health Board/Bwrdd lechyd Prifysgol Cwm Taf Yw enw gwelthredol Bwrdd lechyd Prifysgol Cwm Taf Ascad
Sent To
- CWM Taff University Board
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Aug 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 the 21* September 2017 | commenced an investigation into the death of Howard Winter aged 85. The investigation concluded at the end of an inquest on 1* February 2018. The medical cause of death was Ia. Hospital Acquired Pneumonia, 1b C5-6 vertebral fracture with cord injury, alongside subdural bleeding in the setting of a person with ankylosing spondylitis, Ic Recurrent Falls & 2. Vascular Dementia. The conclusion of the inquest was Accidental Death
Circumstances of the Death
The deceased was a resident at the Daffodils CH, Merthyr Tydfil. He suffered from vascular dementia & had frequent falls. On 23.8.17 he fell in his room, sustained a serious head injury & was taken to PCH, Merthyr Tydfil On 11.9.17 he was diagnosed with a fractured spine: He developed pneumonia & died there on 16.9.17
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.