UK Inquiry Tracker

Herta Woods

PFD Report Historic (No Identified Response) Ref: 2014-0081

Date of Report 26 February 2014

Coroner Veronica Hamilton-Deeley

Coroner Area Brighton & Hove

Response Deadline est. 23 April 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.

View full coroner's concerns

In the circumstances it is my statutory to report to you: (1) The apparent abandoment of this lady in AMU_ (2) The failure to record the and reason for the Doctor's visit (the reason was only illicited from evidence) (3) The failure to seek an early Senior Review for the failure to record the Fluid Chart correctly this is important because it was fluid overload that was the immediate cause of Mrs Wood's death. Her cause of death (a) Acute cardiac failure (b) Fluid overload following administration of intravenous fluid. (c)Acute_renal failure due to dehydration and rhabdomyolysis from day, Warning Mrs. duty timing being:

(d) Fall downstairs resulting in minor physical injuries
2. Hypertensive heart disease and hypertensive chronic kidney disease (4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her. This lady was very likely near the end of her life. However, from the evidence that heard, it was clear that she would not have died when she did had she been given appropriate care and treatment (5) Failure to canulate her appropriately. Her cannula had initially been inserted by ambulance crew; this tissued and needed to be replaced. The requirements concerning cannulation of patients are strict. were not adhered to in Mrs. Wood's case. This should have been dealt with in A & E.

Sent To

Brighton and Sussex University Hospitals

Response Status

Linked responses 0 of 1

56-Day Deadline 23 Apr 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 21st August 2013 commenced an investigation into the death of Herta Edith Maria WOODS The investigation concluded at the end of the inquest on 26th November 2013_ conclusion of the inquest was a Narrative Conclusion:-

Circumstances of the Death

She lived alone with Carers attending upon her: She was a 94-year old lady: There was evidence thatt she had been becoming considerably more confused in the weeks immediately preceding her death. On the 6" August; 2013 she was found by her carers having fallen; an ambulanceywas called; she was cold, had a laceration to her left elbow: The ambulance did a urine dip and this was positive for urinary tract infection. The GP visited bringing with him antibiotics: There was no apparent injury this fall: The next at 09.00 in the morning, Mrs; Woods was once again found by Carers; this time at the bottom of her stairs, lying face-down. She seemed to have fallen some eight stairs and was complaining of neck pain and general discomfort There was a deep wound to her right calf and to her forehead, above her right eye, and pain and bruising to her right shoulder and a skin flap to her right elbow and multiple bruising: She had likely been there for some hours She was cold, and she was taken to hospital: In A & E; observations were taken and X-rays were arranged. She was in atrial fibrillation; She arrived in hospital at 11.20 hours and was eventually admitted to the Acute Medical Unit at 17.00 hours. Although she had the lacerations and bruising described, a CT head scan had not shown any brain injury She did have some Pulmonary Emboli which were not of any great significance She had not passed any urine_ She was suffering from Rhabdomyolysis as a result of the fall, and she was Hypothermic She also had an element of renal impairment and she had passed no urine. This lady was given fluid resuscitation intravenously and she was also given some intravenous Paracetamol for pain. She was written Up for Oramorph; which was never given:. This lady's hospital notes are extremely poor, untimed, frequently incomplete and whilst it was not thought that the poor note-keeping was contributory to her death, it certainly reflects the quality of care with which she was provided. The Fluid Balance Charts, in particular, are not written up correctly and the National Early Scoring System, which is an extremely important way of deciding whether a patient s care needs escalating to at least Outreach Critical Care involvemen; was not adhered to. In addition, there are no Nursing Notes from 20.30 hours; there is no recording of the fact that a Doctor was asked to see her to monitor her urine output She eventually arrived at the AMU at 21.30 hours in the evening and the AMU documentation sheets are completely blank: The only note for AMU is at 01:18 hours on the 8" August 2013 when the Doctor arrives and records that he has been told by the Nurses that Wood had died less than an hour earlier.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action:

Copies Sent To

5. National Patient Safety Agency