Vivian Hunt
PFD Report
All Responded
Ref: 2014-0363
All 1 response received
· Deadline: 3 Oct 2014
Coroner's Concerns (AI summary)
Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
View full coroner's concerns
_ (1) Despite the fall he suffered on 2"d April and despite suffering a clear injury to his face in the fall on 3r April 2014,no neurological observations were made of between 5am on 3rd April and between 12.30 and 13;15pm that
Responses
Action Taken
The Health Board developed a Corrective Action Plan for Improvement to ensure effective action regarding compliance with neurological investigations post head injury, with actions taken by the Mental Health Directorate. (AI summary)
The Health Board developed a Corrective Action Plan for Improvement to ensure effective action regarding compliance with neurological investigations post head injury, with actions taken by the Mental Health Directorate. (AI summary)
View full response
Dear Mr Barkley, Re: Regulation 28 Coroner's Rules Vivian Herbert Hunt (died 4th April 2014) I refer to your email correspondence sent on 6th August 2014, enclosing the Regulation 28 report, which details the areas of concern following your 6th conclusion of the inquest on August 2014 touching on the death of Mr Vivian Herbert Hunt on 4th April 2014. Please be assured that the Health Board has taken this matter extremely seriously and has learnt lessons following investigation and the matters raised at the inquest into the circumstances. Robust action has been to taken to minimise the risk of any recurrence.
1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement was developed to ensure effective action; this is attached.
2. Actions implemented I can confirm that the actions have been taken forward by the Mental Health Directorate with regards to compliance with neurological investigations post head injury; actions still in progress will be monitored through to completion by the Health Board's governance groups. The progress made by 29th September 2014 is reflected in the updated plan as attached. I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mr Hunt and that effective action has now been taken to prevent future deaths. RECEIVED
Bwrdd lechyd Prifysgol $ hi!g Cwm Tat NHS University Health Board WA L ES I would like to convey once again my deepest sympathy and sincere apologies to Mr Hunt's family for the failings identified. If you require any additional information or clarification please do not hesitate to contact me.
1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement was developed to ensure effective action; this is attached.
2. Actions implemented I can confirm that the actions have been taken forward by the Mental Health Directorate with regards to compliance with neurological investigations post head injury; actions still in progress will be monitored through to completion by the Health Board's governance groups. The progress made by 29th September 2014 is reflected in the updated plan as attached. I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mr Hunt and that effective action has now been taken to prevent future deaths. RECEIVED
Bwrdd lechyd Prifysgol $ hi!g Cwm Tat NHS University Health Board WA L ES I would like to convey once again my deepest sympathy and sincere apologies to Mr Hunt's family for the failings identified. If you require any additional information or clarification please do not hesitate to contact me.
Sent To
- Cwm Taff Health Board
Response Status
Linked responses
1 of 1
56-Day Deadline
3 Oct 2014
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 the 4th April 2014 commenced an investigation into the death of Vivian Herbert HUNT aged 84, The investigation concluded at the end of the inquest on 6lh August 2014 The conclusion of the inquest was that Mr Hunt had died from the effects of a subdural haemorrhage following an un-witnessed fall he had in his hospital room on 3rd April 2014
Circumstances of the Death
Mr HUNT was a patient on the Mental Health ward of the Royal Glamorgan Hospital when he was found to have fallen in his room in the early hours of the morning of 3" April 2014 sustaining an injury to the side of his face. He had fallen in similar circumstances the day before: Throughout the he deteriorated until he became unresponsive and a subsequent CT scan showed a bleed on his brain from which he later died the following
Action Should Be Taken
day day_ him day:
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.