Sarah Poole
PFD Report
All Responded
Ref: 2017-0176
All 1 response received
· Deadline: 25 Jul 2017
Coroner's Concerns (AI summary)
There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.
View full coroner's concerns
1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff.
Responses
Action Taken
The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker. An algorithm for how to manage an abnormal ECG has been developed and will be in place for the next Junior Induction in August 2017. A way of summarizing ambulance handover information into 1-2 sheets has been introduced. (AI summary)
The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker. An algorithm for how to manage an abnormal ECG has been developed and will be in place for the next Junior Induction in August 2017. A way of summarizing ambulance handover information into 1-2 sheets has been introduced. (AI summary)
View full response
Dear Mr Siddique RE: PATINT SARAH POQLE DECEASED HOSPITAL NUMBER H19006 DOB 01/03/1978 Firstly, please may express my condolences on the death of Sarah Poole_ write this letter in response to the regulation 28 report to Prevent Future Deaths dated 30th
2017. The concerns raised at the inquest on the 4th April 2017 relate to Miss Sarah Poole and are that there were failures to record and endorse the name of the Doctor reviewing the ECG and the failure to take into account previous abnormal ECG results The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker; i.e. middle grade Doctor or Consultant: This policy will be audited on a monthly basis with 20 sets of ECGs being reviewed to ensure that each ECG has been signed off by Senior Decision Maker and also to audit whether documentation relating to the ECGs is made in the patients notes We have just completed the audit for June 2017 and this shows a 100% compliance with a Senior Decision Maker signing and reviewing the ECG, and 90% compliance with documentation being made in the notes Where there have been omissions the individuals concerned are identified and advised of the requirement to comply with the measures. However, if persist in not complying then the Trust will instigate misconduct proceedings_ Chairman: Chief Executive: David Loughton CBE Rreventing Infection Frotecting Patients Teaching Trust of the University of Birmingham Safe & Effective Kind & Caring Exceeding Expectation 'Oi5abL69 Mi 2382414 1210.16 May being they Fabout #tive the 1 use Number NHS
The department has also developed an algorithm for how to manage an abnormal ECG, which has been approved by the Consultant Body and will be taken to the departmental Governance Meeting for ratification and will be in place for the next Junior Induction in August 2017 . This process will be reinforced during "Focus Fortnight" for Nurses during July 2017. Also, the message will be delivered the Departmental Safety Briefings twice daily as way of reinforcing the new process_ This will also be backed up by posters describing the new process. With regards to the ambulance handover there have been problems with the new electronic handover system producing lengthy documents_ However, we have now introduced a way of summarising this information into to 2 sheets which will be printed off and attached to the ED patient documentation: To ensure that medical staff review this information we have included in the discharge checklist (shared at the inquest) a statement which will ask the clinician to confirm that have read the pre-hospital information: The checklist has been agreed by the Senior Team in ED and is in the process of being incorporated electronically into the printed element of ED patient documentation We cannot confirm at this time the exact implementation date but it will be within the next month, and along with the ECG process we plan to audit the compliance with the discharge checklist on a monthly basis. Please let me know if you require any additional information.
2017. The concerns raised at the inquest on the 4th April 2017 relate to Miss Sarah Poole and are that there were failures to record and endorse the name of the Doctor reviewing the ECG and the failure to take into account previous abnormal ECG results The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker; i.e. middle grade Doctor or Consultant: This policy will be audited on a monthly basis with 20 sets of ECGs being reviewed to ensure that each ECG has been signed off by Senior Decision Maker and also to audit whether documentation relating to the ECGs is made in the patients notes We have just completed the audit for June 2017 and this shows a 100% compliance with a Senior Decision Maker signing and reviewing the ECG, and 90% compliance with documentation being made in the notes Where there have been omissions the individuals concerned are identified and advised of the requirement to comply with the measures. However, if persist in not complying then the Trust will instigate misconduct proceedings_ Chairman: Chief Executive: David Loughton CBE Rreventing Infection Frotecting Patients Teaching Trust of the University of Birmingham Safe & Effective Kind & Caring Exceeding Expectation 'Oi5abL69 Mi 2382414 1210.16 May being they Fabout #tive the 1 use Number NHS
The department has also developed an algorithm for how to manage an abnormal ECG, which has been approved by the Consultant Body and will be taken to the departmental Governance Meeting for ratification and will be in place for the next Junior Induction in August 2017 . This process will be reinforced during "Focus Fortnight" for Nurses during July 2017. Also, the message will be delivered the Departmental Safety Briefings twice daily as way of reinforcing the new process_ This will also be backed up by posters describing the new process. With regards to the ambulance handover there have been problems with the new electronic handover system producing lengthy documents_ However, we have now introduced a way of summarising this information into to 2 sheets which will be printed off and attached to the ED patient documentation: To ensure that medical staff review this information we have included in the discharge checklist (shared at the inquest) a statement which will ask the clinician to confirm that have read the pre-hospital information: The checklist has been agreed by the Senior Team in ED and is in the process of being incorporated electronically into the printed element of ED patient documentation We cannot confirm at this time the exact implementation date but it will be within the next month, and along with the ECG process we plan to audit the compliance with the discharge checklist on a monthly basis. Please let me know if you require any additional information.
Sent To
- Royal Wolverhampton NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
25 Jul 2017
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 4 April 2017, I commenced an investigation into the death of the late Mrs Sarah Poole. The investigation concluded at the end of the inquest on 16 May 2017. The conclusion of the inquest was a narrative conclusion: Natural causes contributed to by neglect.
The cause of death was:
1a Cardiac Dysrhythmia (Ventricular Fibrillation) b Cerebral Anoxia/Brain Injury c Acute Aortic Dissection with Aortic Rupture and Cardiac Tamponade (Operated 29/10/2016) ll Hypertension
The cause of death was:
1a Cardiac Dysrhythmia (Ventricular Fibrillation) b Cerebral Anoxia/Brain Injury c Acute Aortic Dissection with Aortic Rupture and Cardiac Tamponade (Operated 29/10/2016) ll Hypertension
Circumstances of the Death
i) Ms Poole was admitted to New Cross hospital after complaining of sudden onset of headache and back pain on the 28 October 2016 shortly after 11pm. ii) An ECG performed by ambulance staff was abnormal. She was then triaged by nursing staff and assessed at Level 4 before being given pain relief medication. iii) She was seen by a doctor at 1:50am who recorded a history of anxiety and panic attacks, headaches and pain in her back and chest. Her observations were normal and it was incorrectly concluded that her ECG was normal when the wrong ECG was examined relating to another patient. iv) She was later discharged home and no discharge papers were given to the family. v) Her condition continued to decline and she was readmitted back to hospital on the 29 October at around 1pm; a scan and further investigation revealed an aortic dissection. vi) She then had emergency surgery which was a complex operation with
[IL1: PROTECT] associated risks. vii) She developed further complications post operatively and by the 3 November a CT brain scan revealed minimal brain activity. She sadly passed away on the 5 November 2016.
[IL1: PROTECT] associated risks. vii) She developed further complications post operatively and by the 3 November a CT brain scan revealed minimal brain activity. She sadly passed away on the 5 November 2016.
Action Should Be Taken
1. I understand that since this incident a number of measures have been introduced including reinforcing the requirement to sign all ECG’s. However, a recent audit (May 2017) indicated that out of twenty cases examined there were still two failures by the clinician to endorse the ECG.
2. You may wish to consider setting up a review of the policy and training for the relevant staff concerned and a consideration of an escalation policy for those who continue to fail to adhere to policy and instructions.
2. You may wish to consider setting up a review of the policy and training for the relevant staff concerned and a consideration of an escalation policy for those who continue to fail to adhere to policy and instructions.
Copies Sent To
Senior Coroner Black Country Area
[IL1: PROTECT] [IL1: PROTECT] 3
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.