Frederick Sutton
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.
View full coroner's concerns
(1) The staffing levels in the hospital during his seemed to be less than optimal: (2) Whilst there is a procedure for escalation of the shortage of staff, this was either not fully understood or not properly put into effect: (3) There was clear evidence that a nurse had failed to read (or read properly) the nursing notes_ (4) The computerised note keeping system used in the Emergency Department is not able to "talk to" the system which covers the rest of the hospital: (5) The patient required the administration of cyclazine and there was an obvious problem with the (lack 0f) training of the staff in this regard.
(6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to. There seemed to a lack of training amongst the staff as to the_ July stay administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery_ (8) There was a general lack of care as to the accuracy of the information held by the hospital as to next-of-kin details, where the wife of the deceased was shown as no.k when in fact she had died in 2008
(6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to. There seemed to a lack of training amongst the staff as to the_ July stay administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery_ (8) There was a general lack of care as to the accuracy of the information held by the hospital as to next-of-kin details, where the wife of the deceased was shown as no.k when in fact she had died in 2008
Sent To
- Stockport NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
22 Oct 2015
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 9"h February 2015 commenced an investigation into the death of Frederick Sutton dob 13th September 1930. The investigation concluded on the 14" 2015 and the conclusion was one of Accidental death The medical cause of death was Ia Myocardial Infarction 1b Coronary Artery Atheroma 11. Fractured right hip (Traumatic)
Circumstances of the Death
On the 3r February 2015 at his home address he fell and broke his hip. He may have suffered a myocardial infarction at the same time: He was admitted to hospital and died approximately 12 hours later:
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.