Patricia Norfolk
PFD Report
Historic (No Identified Response)
Ref: 2017-0438
Coroner's Concerns (AI summary)
Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.
View full coroner's concerns
That patients, such as the deceased, were not being receiving a daily senior clinician review. I have been appraised of the developments that the Trust is aspiring to in relation to senior daily reviews and decision making and recognise the steps the Trust is taking to recruit appropriate staff to undertake such reviews. However, I remain concerned regarding what happens to patients in the interim period pending recruitment and appointment.
Sent To
- Pennine Acute NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
30 Aug 2017
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 1 June 2016 I commenced an investigation into the death of Patricia Norfolk. An inquest was held and concluded on 8 March 2017.
Circumstances of the Death
The deceased was admitted to Royal Oldham Hospital on 13 May 2016 following discovery of a fractured neck of femur. The deceased had 2 unwitnessed falls in March 2016 and she attended Royal Oldham Hospital on 18 March 2016. However, the fracture was not discovered until 2 months later in the absence of X-ray investigation on presentation to Royal Oldham Hospital in March 2016. The deceased developed an infection following surgery and she continued to deteriorate despite appropriate medical intervention. She died from bronchopneumonia following discharge from the hospital to Braeside Care Home. Fact of death was confirmed at 20:30 pm on 27 May 2016 My conclusion at inquest was that the deceased died from a recognised complication of necessary medical intervention.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.