Denise Prior
PFD Report
All Responded
Ref: 2014-0262
All 1 response received
· Deadline: 28 Jul 2014
Coroner's Concerns (AI summary)
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
View full coroner's concerns
In the circumstances it is my statutory duty to report to_YOU_ being again any yet
_ That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription, and in the application or departure the NEWS' system.
_ That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription, and in the application or departure the NEWS' system.
Responses
Action Taken
Western Sussex Hospitals NHS Trust has undertaken a thorough investigation and review and enclosed an action log setting out the action taken. (AI summary)
Western Sussex Hospitals NHS Trust has undertaken a thorough investigation and review and enclosed an action log setting out the action taken. (AI summary)
View full response
Dear Mr Kendall RE: Inquest into the death of Denise PRIOR ~ Regulation 28 response Thank you for your letter dated 3 June 2014, The Trust has undertaken a thorough investigation and review into the areas in which you raised concern and is pleased to enclose an action log setting out the action taken. hope that you will be reassured by the actions taken by the Trust and please do not hesitate to contact me should you require any further information or clarification.
Sent To
- Western Sussex Hospitals NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
28 Jul 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 20th May 2014 I concluded the inquest into the death of Denise PRIOR, born 18th February 1943 (aged 60 years) who died on 6th November 2013' Mrs Prior had died as a result of (1a) Global hypoxic ischaemic injury to the brain (1b) Hypoxia (1c) Facial injuries sustained in witnessed fall (29/10/13) (II) Debridement and closure of facial laceration, MUA plus oris of fractured nasal bones. Closure of intra oral laceration (successful 30/10/13). I determined that "The deceased died from a cardiac arrest following a fall caused by her underlying medical condition.
Circumstances of the Death
Denise Prior died from the consequences of a cardiac arrest following fall, which in turn had been caused by her underlying medical condition. During inquest considerable attention was given to the concerns of Mrs Prior's family arising from the records of Mrs Prior's treatment at St Richards, which is part of the West Sussex Hospitals
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.