Zawdie Bascom
PFD Report
Historic (No Identified Response)
Ref: 2016-0227
Coroner's Concerns (AI summary)
Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to unmitigated severe pain at discharge. Audit plans also failed to address general severe pain cases.
View full coroner's concerns
In the circumstances _it is my statutory duty_to report to YOU The May May May May
_
1) Mr Bascom presented in severe pain to A&E: This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E
2) Analgesic medication was administered at 03.45 a pain score recorded at 05.15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.
3) Further analgesia in the form of tramadol was given at 05.30. There was no further pain score recorded following this analgesia. No score was recorded prior to discharge.
4) On the basis of the evidence heard found that Mr Bascom's pain was not relieved prior to discharge. There was no documentation at all to support pain relief and confirmed that Mr Bascom continued to require support as a result of the pain;, when he left the hospital: The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.
5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The Consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain. No pain score was recorded by any member of the nursing team: There was no evidence of any systematic assessment of (for example, response to analgesia).
_
1) Mr Bascom presented in severe pain to A&E: This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E
2) Analgesic medication was administered at 03.45 a pain score recorded at 05.15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.
3) Further analgesia in the form of tramadol was given at 05.30. There was no further pain score recorded following this analgesia. No score was recorded prior to discharge.
4) On the basis of the evidence heard found that Mr Bascom's pain was not relieved prior to discharge. There was no documentation at all to support pain relief and confirmed that Mr Bascom continued to require support as a result of the pain;, when he left the hospital: The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.
5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The Consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain. No pain score was recorded by any member of the nursing team: There was no evidence of any systematic assessment of (for example, response to analgesia).
Sent To
- Barts Health NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
15 Aug 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 the 8"h September 2015 opened an inquest into the death of Mr Zawdie Ogunseye Bascom The investigation concluded at the end of the inquest on the 17lh June 2016. conclusion of the inquest was natural causes contributed to by neglect:
Circumstances of the Death
Mr Bascom was a 38 year old gentleman who suffered an onset of severe abdominal pain on Saturday 10lh 2014. He presented to A&E at Newham General Hospital with the primary presenting complaint of severe pain and was assessed by a triage nurse and then a locum SHO. The SHO carried out an abdominal examination which revealed a non-distended, hard and rigid abdomen: Observations were noted to be within normal limits, as was a full blood count: Venous blood gases however revealed a low pH 217) and a raised lactate (2.2). Only one pain score was recorded during the course of the 5 hour attendance to A&E, despite the reason for attendance being severe pain. Mr Bascom was discharged from hospital with a presumed diagnosis of gastritis. Mr Bascom remained in severe pain throughout the 1 2014 and presented to his GP on the 12th 2014. The GP was provided with a discharge summary from A&E which included reference to no raised inflammatory markers and a normal chest X-ray: The GP was not informed of the abnormal venous blood gas results_ The GP changed the prescription of lansoprazole to omeprazole and recommended that Mr Bascom should return to A&E if the pain persisted or if he had no relief to the medication given: Mr Bascom collapsed at around 21:00 hours on the 12/h 2014 and in spite advance life support by paramedics and in hospital, he passed away on the evening of 12/h May 2014 at Newham University Hospital. A post mortem examination confirmed a cause of death of 1a) Peritonitis 1b) Rupture of Inflamed Vermiform Appendix:
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.