UK Inquiry Tracker

Patricia Chapman

PFD Report All Responded Ref: 2015-0159

Date of Report 23 April 2015

Coroner Andrew Tweddle

Coroner Area County Durham & Darlington

Response Deadline ✓ from report 18 June 2015

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 18 Jun 2015

Coroner's Concerns (AI summary)

Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.

View full coroner's concerns

_ (1) The revised training and flow chart does not include any reference to staff in a community hospital being able to obtain emergency advice from an expert in the emergency department of one of the Trust's acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after having been summoned: It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying t0 ensure a patient's safety and this is not included in the revised Trust policies. This is something that should be given consideration to

Responses

County Durham and Darlington NHS Trust NHS / Health Body

Action Taken
The Trust has trained qualified staff at Sedgefield Community Hospital in managing deteriorating patients and hypoglycemia. They have introduced an operational procedure for community hospital staff to seek urgent advice from acute hospital staff while waiting for an ambulance, including contact numbers for medical consultants and registrars. (AI summary)

View full response

Dear Patricia Lillian Chapman am responding to content of your letter and specifically those issues raised within your report under Regulation 28 and 29 of the Coroners Investigations Regulations 2013. The Matters of Concern as you stated: The revised training and flowchart does not include any reference to staff in a community hospital being able to obtain emergency advice from an expert in the emergency department of one of the Trust's acute hospitals (or from an expert in another department of the said hospitals if appropriate) t0 assist in giving immediate medical cover whilst; for example, other steps are being taken or whilst an ambulance is on route after being summoned. It may be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient's safety and this is not included in the revised Trust policies. This is something that should be given consideration to. This letter is to confirm that all qualified staff at Sedgefield Community Hospital have received training in the deteriorating patient and management of a patient with hypoglycaemia. If a patient with diabetes is admitted to any community hospital the "Management of Hypoglycaemia" flowchart is inserted into the front of the nursing care record to act as a reference WWW cddft nhs.uk Chief Executive , Darlington Memorial Hospital, Hollyhurst Road, Darlington; County Durham DL3 6HX Tel: 01325 743565 Sir, the well guide.

We have also introduced an operational procedure for community hospital staff who may require urgent advice whilst waiting for an ambulance to arrive, as follows: OPERATIONAL PROCEDURE COMMUNITY HOSPITALS On occasion it may be necessary to seek urgent advice on the management of a patient within a community hospital whilst waiting for an emergency ambulance t0 arrive. Process to follow
1) Dial 999 always first action.
2) Ensure registered nurse stays with the patient_
3) Implement immediate actions as per trust policy:
4) Summon on site qualified medical practitioner_ If urgent advice is required whilst waiting for an ambulance and there is no qualified medical practitioner on site: Contact acute hospital switchboard Telephone No. 01325 380100 Between 8 OOam
8.OOpm each ask for Medical Consultant Physician of the Between 8 OOpm 8 OOam each ask for Medical Registrar on call Be concise regarding the immediate advice you require and what the issues are regarding patient management whilst waiting for an ambulance to arrive.

Sent To

County Durham and Darlington NHS Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 18 Jun 2015

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"h July 2013 | commenced an investigation into the death of PATRICIA LILLIAN CHAPMAN; Aged 77 years. The investigation concluded at the end of the inquest on 21st April 2015 conclusion of the inquest was "The avoidable consequence of an avoidable hypoglycaemic episode" . with a cause of death of Hypoglycaemia

Circumstances of the Death

The deceased was a patient at Sedgefield Community Hospital. In the altemoon of the 8"h of July 2013 she had a severe Hypoglycaemic attack but following an injection , apparently recovered: In the early morning of the next day she died from another Hypoglycaemic attack: The inquest has revealed a number of shortcomings with regard to the deceased'S care. changes in practice policy and procedure have been implemented since her death:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: YouR RESPONSE You are under a duty to respond to this_ report within 56 days of the date of this report The Many The namely by 18 June 2015. |, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed:

Copies Sent To

SCHEDULE 5 paragraph ACTION To PREVENT Otker DEATKS 28.= This regulation where a coroner is under a under paragraph 7 of Schedule 5 t0 make a report to prevent other deaths In this regulation, a reference to "a report" means a report to prevent other deaths made by the coroner report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation of Schedule 5_ In this regulation, a reference to "a report" means a report to prevent other deaths made by the coroner: applies duty response must be provided to the coroner who made the report within 56 days of the date on which the report is sent coroner who made the report may extend the period referred to in paragraph (even if an application for extension is made after the time for compliance has expired) (b) or (c)) Representations under paragraph must be made to the coroner no later than the time when the response to the report to prevent other deaths is provided to the coroner under paragraph coroner must pass any representations made under paragraph