UK Inquiry Tracker

William Winter

PFD Report Historic (No Identified Response) Ref: 2014-0154

Date of Report 7 April 2014

Coroner Rachel Redman

Coroner Area Kent (Central & South East)

Response Deadline ✓ from report 2 June 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.

View full coroner's concerns

Mr Winter was admitted to the CDU at 8pm and the nursing staff were concerned that he had not been reviewed by the surgical team. They missed carrying out a second set of observations soon after 2am on 26th March 2013 owing to the pressures on them to care for other patients on the Clinical Decisions Unit. Mr Winter was found in a unresponsive state at approximately 5am on 26th March 2013 when efforts were made to resuscitate him during which it was noted that rigor mortis had already developed.

I heard evidence that there were 19 admissions and discharges to and from the CDU overnight with 4 members of nursing staff. It was apparent that whilst keeping an eye on Mr Winter, they did not carry out a second set of observations when they should have done nor did they escalate their request for a surgical review. They were unfamiliar with how to do this.

Sent To

East Kent Hospitals University NHS Foundation Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 2 Jun 2014

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 10th April 2013 I commenced an investigation into the death of William Albert Winter. The investigation concluded at the end of the inquest on 27th March 2014. The conclusion of the inquest was that Mr William Albert Winter died as a result of surgery for the repair of an abdominal aortic aneurysm.

Circumstances of the Death

Mr W A Winter was admitted to William Harvey Hospital on 25th March 2013 after discharge from St Thomas’ Hospital on 22nd March 2013 for the repair of an abdominal aortic aneurysm. He was admitted to the Clinical Decisions Unit at about 8pm at William Harvey Hospital and found in an unresponsive state with rigor mortis at approximately 5am on 26th March. Resuscitation attempts were abandoned soon after.

Action Should Be Taken

This was the second inquest I have conducted in which someone has died in the CDU and had already developed rigor mortis when it was noticed that they were unresponsive. The first case touched the death of Beryl Hopper who died on 19th February 2013 whose inquest I closed on 5th March 2014. I am concerned that the staff on CDU are overlooking the needs of their patients owing to the pressures they face. However, I note in the After Action Review Report that lessons have been learnt and that the recommendations identified in the Report have already been actioned.

Copies Sent To

niece of the deceased