Barbara Turner
PFD Report
Historic (No Identified Response)
Ref: 2016-0386
Coroner's Concerns (AI summary)
The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.
View full coroner's concerns
It is also my opinion that the nature of these issues are such that URGENT ACTION needs to be taken: _ (1) The Trust Policy and Protocol for Resuscitation states at Appendix 3 that the call out criteria for the Adult Resucitation Team is AII Cardiac Arrests AII Respiratory arrests Unresponsive_patient or visitor with Heart rate Heart rate Respiratory rate >40 Respiratory rate < 8 Systolic BP 80 mmHg Oxygen Saturations 90% Had these criteria been applied to Mrs Turner then the resuscitation team would not have been called, despite clinicians who gave evidence to the court that she was critically ill, The court heard evidence that person's suffering an intracerebral event or head injury can be critically ill and in need of resuscitation but have initial normal vital signs parameters_ It may be that in the policy and protocol the parameters for critically_ill unresponsive_ and The Any patients are too broad and as a consequence proportion of critically ill patients will be denied the best possible chance of being treated by a skilled resuscitation team_ (2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant; who gave evidence_ as 'dangerous_ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA; with appropriate vital signs monitoring resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway
Sent To
- Derby Teaching Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
24 Dec 2016
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 12th May 2015 commenced an investigation into the death of Barbara Turner, Aged 81 years The investigation concluded at the end of the inquest on 21s October 2016. The conclusion of the inquest was that Mrs Turner died from: Ia. Multi organ failure_ 1b. Acute Myocardial infarction: Ic. Acute Intracerebral event: II. Systemic Hypertension, Atrial Fibrillation, Post-Operative knee replacement: My conclusion was that: Barbara Turner died from a recognised complication of a necessary surgical procedure
Circumstances of the Death
Mrs Turner was an 81 year old lady who was admitted to the Royal Derby Hospital on the 6th May 2015 for an elective left total knee replacement: The operation was undertaken on the same day and she returned to ward 206 at 18.30 hours At around 21.47 hours she was found unresponsive by the nursing staff. Who called the SHO in orthopaedics to attend. She underwent a CT scan and was admitted to ITU where she died on the 1t May2015
During the course of the inquest the following facts were found: There was & failure to undertake vital signs observations on six occasions was contrary to the established orthopaedic protocol for observations in force 2t the time of Mrs Turner's admission There was a failure by the nursing staff who found Mrs Turner unresponsive and unconscious to appreciate how critically ill she was and thus called the orthopaedic SHO to attend to Mrs Turner by the usual methods There was a failure by the attending SHO to appreciate how critical ill she was and consequently a failure to summons appropriate and senior medical assistance. There was a failure to summons that assistance by means of a 'crash" call to the Resuscitation Team; Nursing staff were unaware of the procedures of the Trust Policy: ' Policy and Procedures for Resuscitation There was a failure to escort Mrs Turner to the CT scanner and return t0 the ward in a safe manner; There was inadequate monitoring, no emergency equipment and in the opinion of the Trust's ITU consultant no appropriately trained staff for the escort who could deal with airway management and medical emergencies en route to the scanner; in the scan room and return to the ward_ The ITU consultant in evidence described this action as dangerous_ court found it to be palpably dangerous and wrong: The Court found these to be gross failures, however on the evidence the court found that none of these failures had caused or contributed to Mrs Turner's Death
During the course of the inquest the following facts were found: There was & failure to undertake vital signs observations on six occasions was contrary to the established orthopaedic protocol for observations in force 2t the time of Mrs Turner's admission There was a failure by the nursing staff who found Mrs Turner unresponsive and unconscious to appreciate how critically ill she was and thus called the orthopaedic SHO to attend to Mrs Turner by the usual methods There was a failure by the attending SHO to appreciate how critical ill she was and consequently a failure to summons appropriate and senior medical assistance. There was a failure to summons that assistance by means of a 'crash" call to the Resuscitation Team; Nursing staff were unaware of the procedures of the Trust Policy: ' Policy and Procedures for Resuscitation There was a failure to escort Mrs Turner to the CT scanner and return t0 the ward in a safe manner; There was inadequate monitoring, no emergency equipment and in the opinion of the Trust's ITU consultant no appropriately trained staff for the escort who could deal with airway management and medical emergencies en route to the scanner; in the scan room and return to the ward_ The ITU consultant in evidence described this action as dangerous_ court found it to be palpably dangerous and wrong: The Court found these to be gross failures, however on the evidence the court found that none of these failures had caused or contributed to Mrs Turner's Death
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action,
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.