UK Inquiry Tracker

Marie Rollason

PFD Report All Responded Ref: 2016-0100

Date of Report 24 February 2016

Coroner Zafar Siddique

Coroner Area Black Country

Response Deadline ✓ from report 25 April 2016

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 25 Apr 2016

Coroner's Concerns (AI summary)

The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital readmission.

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Evidence emerged during the inquest that Mrs Rollason had at least five periods of loss of consciousness at home by the time she visited her GP's Practice on the 23 December 2015_ When she was admitted back to the Hospital on the 23 December 2015, an

Responses

Royal Wolverhampton NHS Trust NHS / Health Body

22 Apr 2016

Action Taken
The Royal Wolverhampton NHS Trust confirms that clinical staff in the Emergency Department receive regular training in the identification and treatment of pulmonary embolism. A training session on venous thromboembolism has recently been delivered, and ECG interpretation is included in training sessions. (AI summary)

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Dear Mr Siddique Re: Requlation 28: Report to Prevent Future_Deaths: Mrs Marie Rollason Inquest 19th February 2016 Thank you for your correspondence dated February 2016 regarding the outcome of the inquest into the death of Mrs Marie Rollason, concluding 19th February 2016. With respect to the action to be taken under regulation 28: report to prevent future deaths this was set out as follows: In my opinion action should be taken to prevent future deaths and believe you have the power to take such action"_ review should take place in the identification and treatment of pulmonary embolism and consideration of further training in the interpretation of ECG results for the staff involved _ can confirm that the clinical staff in the Emergency Department have regular training in the identification and treatment of pulmonary embolism and this subject is standard item on the teaching curriculum. A training session on venous thromboembolism has recently been delivered within the Emergency Department: The clinical staff directly involved in the management of Marie Rollason will have individual training in the interpretation of ECG findings in patients with pulmonary embolism specifically: Abnormalities in ECG tracings associated with pulmonary embolism are also included in the above noted training sessions_ If you do require further information please do not hesitate to contact me

Sent To

Royal Wolverhampton, New Cross Hospital

Response Status

Linked responses 1 of 1

56-Day Deadline 25 Apr 2016

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 30 December 2015, commenced an investigation into the death of Mrs Marie Rollason. The investigation concluded at the end of the inquest on 19 February 2016. The conclusion of the inquest was the deceased died by way ofnatural causes contributed to by neglect. The cause of death was: Ia. Pulmonary Embolism

Circumstances of the Death

Mrs Rollason was a 43 year old woman who sustained a head injury during a fall in her bathroom at her home on the 19 December 2015. She was admitted to New Cross Hospital Emergency Department Wolverhampton at around 11.45pm. The laceration was sutured and computerised topography (CT) scan performed. The CT scan did not show any evidence of fractures or haemorrhages_ The injury was recorded as a laceration to the right side of forehead after a fall She was later discharged home the following morning on the 20 December shortly before 4am. She was provided with a leaflet advising that if she had any further loss of consciousness then she should seek medical attention. Over the course of the next several days she had & number of periods of loss of consciousness and was re-admitted back to the Accident and Emergency Department on the 23 December after she collapsedlfainted at her GP's surgery. She was examined at the same Hospital and her observations recorded An electrocardiogram (ECG) trace was also recorded. This revealed an abnormality in the trace which can be indicative of changes that occur during pulmonary embolism. However the Junior Doctor recorded the ECG trace 'was okay" and she wasn't kept in for further observation but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP_ She continued to have fainting spells and loss of consciousness at home and then on_the_29_December_collapsed_again_ at_her_GP's_surgery_and_sadly: [ILI: PROTECT]

despite resuscitation attempts she died

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power t0 take such action. review should take place in the identification and treatment of Pulmonary Embolism and consideration of further training in the interpretation of ECG results for the staff involved.