Stuart Aaron Collins
PFD Report
Partially Responded
Ref: 2013-0300
Coroner's Concerns (AI summary)
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
View full coroner's concerns
1. There appeared to be a degree of uncertainty as to whether Mr Collins was assessed upon his arrival at the A&E department at James Cook University Hospital (“the hospital”)at approx. 00.45 or whether information previously obtained by paramedics was utilised in lieu of an assessment on arrival.
2. It was stated that Mr Collins should have had hourly nursing observations taken during his first admission to A&E on 9.10.12, ie between 00.45 and his discharge at 04.30, but none were taken.
3. Evidence was given that Mr Collins was added to the whiteboard in the A&E dept but that the information regarding the frequency of his nursing observations was not. It was stated that this led to no nursing observations being taken during his first time at A&E on 9.10.12
4. Evidence was given that the nursing notes in A&E were not fully completed and were not kept up to date. There was no apparent recording about Mr Collin’s epilepsy or the need for the hand sanitiser gel to be moved out of his reach.
5. Evidence was given that the hand sanitiser gel was collected from the A&E department. However further evidence was given that the collected hand gels (estimated at 20 in number) were placed on the nurses station very close to Mr Collin’s cubicle. There was contradictory evidence as to whether Mr Collins could have accessed the hand gel from the nurses station.
2. It was stated that Mr Collins should have had hourly nursing observations taken during his first admission to A&E on 9.10.12, ie between 00.45 and his discharge at 04.30, but none were taken.
3. Evidence was given that Mr Collins was added to the whiteboard in the A&E dept but that the information regarding the frequency of his nursing observations was not. It was stated that this led to no nursing observations being taken during his first time at A&E on 9.10.12
4. Evidence was given that the nursing notes in A&E were not fully completed and were not kept up to date. There was no apparent recording about Mr Collin’s epilepsy or the need for the hand sanitiser gel to be moved out of his reach.
5. Evidence was given that the hand sanitiser gel was collected from the A&E department. However further evidence was given that the collected hand gels (estimated at 20 in number) were placed on the nurses station very close to Mr Collin’s cubicle. There was contradictory evidence as to whether Mr Collins could have accessed the hand gel from the nurses station.
Responses
Noted
The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and observations were taken, but dispute the frequency of observations. (AI summary)
The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and observations were taken, but dispute the frequency of observations. (AI summary)
View full response
peapul pue Koiod zsnu} Juaun? YIIM ojuepjoooe UI pabeueul 910j8184} SeM SuIlo? JW ueid Apinoy V &4} uey} uollenasqo JO /3181 Juanbajy aJOU e paua66u} 84EY JoU pinom SI4} Koijod Isnu} 0} buipjoooe pue uoissiupe uo Z se pejeinojeo sem &103S fuuJeM Apue3 sulllo? JW 'buuoluou leoibojoiskyd auiinoj JO} spjepueis Wnllul Ino slas slualled pasieiidsoH Inpv U sseulll a1noV 0} asuodsay pue 40/1lubo3ay 981D Kollod Isnu} &41 uaxe} SeM auou inq O8:+0 Je #6ey3Sip S/y pue Gv*00 ubamiOq '8" Zl*0l"6 uo 38V 0} uoissiupe JSII} S/y fuunp uaxe} suoilelasqo buisinu Kpunoy pey #^e4 pinoys suiiio) AW Je4} pazeys Sem H 2 "1! 3N92a1 01 peib &q pinom 'Kuejjuos a4} 01 Kue &eY no JI uollejuaunoop s,pipauejed &4} WOJJ paido? aJ8M suolenlasqo Jno Jey} 1sa66ns 01 ajuapia ou pui ueo aM saiiliqesip pue uollenouo 'bulyleauq 'Kemule $,Jualed buissasse 'ypeoudde @381 paseq avuap1? ue pasn &H OSJnN a6ue43 Kq IeNIJe Sly UO pabeiu} SeM sull/o) JW Jey} Blejisuouap spj0jaJ 381 Je4L 'IeAlJe uo Juaussasse ue J0 nall U! pasiilin SeM soipaweaed Wox} pauieiqo Kpsnolaud UOIJeWJoJul Jaynaym 10 Gv:00 Kjoneuixojdde Je ( leldsoy &41,) IeJdsoH Kwsjanun Xoo? saler Je quauuledap 3rv a4} Je |enluJe Sly uodn passasse Sem sulllo? JW Jayjaym 0} se Kzuleazun Jo aa1bap aq 0} pajeadde a1341 'suoilenasqo bulmollog a4} axeuu pinom sjuiod oilipads Jnof 0} Jamsue UI "Isonbul 841 Je Jlesunok Kq pasiej Slejew 34} OJU1 uojjebiIsaAUI Ilny e ino pauue? &EY & pue uollesiuebio 34} U/ /84a1 Jojuas e 1e passnosip uaaq seU Jauel SIy} Jey} nof ainsse 01 axil pinom Eloz suoieinba $,Jauojo3 JO 8Z uolleinbay Japun JOquaAON 81 JO Jaj1ei Jnof 0} asuodsal UI 6uIJm We SNI7703 NOUVV LYVnls 40 HIVaC 3HL OLNI LSAOONI SW Jeea Coz LSL Honouasgnaa1W peoy uaqiV IleH UMoL Ybnouqsaippiw ODNOS Sauojo3 a4L eaJV Jauojo) apissaaL Jauojo) JueISISSV Kajied ? SW #lOz Kuenuer 0z JUIMOH/HL nSUL SaaLinoS WUM :alls-qaM Ma: +SL 'qbnolqsaIppIW peoy uopeW leiidsoH Kiisjaun 70o3 saluer buipiing KeJinW &41 a3100 s,a4/inoax3 J8/43 1snuL uollepunoy SHN [HN sieldsoH sa31 Ynos a41 Juas a4} Kallea a41
'apeu &q 0} pey sluaied pue JleIs 41oq 0} XSIA JO &oueieq a41 J0 Juauabpnl e ajojajayl koljod aua16fH puehi a41 Vl DIH Koilod zsnul 4HIM auil UI Wau} &sn 0} pajinbaj aJe JleJS Se 'eaue &4} WUQJ} pBAOW8I /jajaiduo? aJam sJasuadsip 'squailed Jayio JO} YSIJ aseajoui paapul pue Diisileaiun aq pinom Jey} uojuido ay} Jo Sl uoijesiuebuo &41 Sulo? JWN Jo Kquoi 941 U pOAOWaJ aJ8M sjasuadsip JSIIYM '48as ueaq bupey IenpINpul a4} Inoylm Kjaxlun suaas SI4L 'juauuuedap &4} Ul sjayjo pue uolleis a41 Je Hleis a41 0} Jueuuedap 46n014} XleM pue Sly WOJJ Jlasuly JAOWOJ 0} pey a^ey pinom &4 uolleis sasunu Je [a6 &4} ssa33e 04 sulllo) JW JQ} Jepio UI os Kep e sinoy VZ JleIs Kq pauueu S! SI4L uolleis sasinu Iemlua? WoJ} aqISM aJe sappiqno Ile Iey} seunsua Juauuedap &4} JO Ubisap 841 quauuedaa 38V &4} Jo appilu 94} S! Y214M uoljeis sasunu |ejqua? a41 J0 aje Xsap e UO 1oe} Ul aJam sullo) JW Aq peidnooo jeoiqnj a4} 01 as0p2 pavejd JOU #J8M puey paiouaj a4} Jey} Jollaq Jno sl Hl uohlels sasanu a41 lox} puey passazze a^e4 pino) suliio) WW Jay1a4m 0} se a3uapia Aopoipemhuo? SEM 9Ja41 appiqn3 .suIlIO) JW 0} asopp Kjan uohieis sasunu ay} uo pazeid a43M (1aqunu 4i 0z 1e poveullsa) sja6 puey pavjaiio? a4} Je4} uanib SEM a3uapiaa Jayuany JaaaMoH 'quaupuedap 381 a4} Woj} paijallo? Sem jasiiues puey Jey} uanis Sem a3uapia3 snoauejoduajuo? Kjajaiduuo? Jou aJe spJ03a1 buisunu a41 JeY} Ideooe &M 'a1ou uolleJS ,sesinu |eJjua? 34} Je paoeid pue paAowal aJaM eaje Jeau ui sjosuedsip 1a6 Jaslues Ile Jey} UOIJEWjojul 94} 0} esuodsal Ul sem !| Jolpop buipuane &41 01 Kuo1sly suillo? JWN 1461/46/4 pue ueId Juauabeuelu &4} 0} Jajaj O1 asunu a4} paiduojd pue pabpajmouxpe sem J! Jey} Juaunoop 0} esunu ab1ey2 e Kq paubis sem 341 'KJoJsIy Ieoipau Ised S/y YIIM Jelllle} Kan Mileinjeu aJ0jaja4} aJem Jleis (siuol 'Zl snoiaid 94} Ul as84} JO €9 YIIM |eJo} Ul SOUl} LL) Juauuedap ay} Ul Japuehe Jeinbaj uaeq pey ay Moux noa sV apeid U1 Juauabeueu e pey pue axinas &4} 0} UMOUX SeM 84y Jey} paijuapi YDI4M pJ02a1 Sly UO 6el} UOIJeuJolul Juaied Ieoi1uu? e pey Sulllo) JW Jey} Qulod 5/4} Je paiou sem H| ajuepuatle Ul asunu abe4? &41 Kq Juaussasse obe14} ay} buuunp wa1sKs piuojpoaia 38V ay1 OJul pajajua ajam sllejap sullloj JW 'Ypea1 SIY J0 }no paAOU &q 0} Jashiues puey a4} 4O} paau a4} 40 Ksdallda Isuilioj JW wnoqe 6ulp4o3au Jualedde ou SeM 81841 "atep 0} dn Idax IoU alam pue pajaiduo? Kiin} JoU aJ8M 38/ U! sa10u fuisinu 04} Je4} U9nl6 sem a3uapia3 'p 'uejd juauabeueu |eoIulp? Jay} epnpul Jou pIp inq ajuas81d s,Juailed 841 pJoJaJ 0} pasn Sem Juaupedap U! pJeoq a1lym &41 uoissiupe ,sulllo) JW JO awi} }V 'Eloz Jeqo1oo Ul paonpoJju seM S/y} 'paiou aje suoijebIsaAUl oilpads pue suoienesqO Jeinbaj Buuinbaj sluailed ajaym pleoq a3i1ou e pjajia Ui Sl YQ14m apleog a3uein Je snieis Juailed, @ Se Umoux Si Jeym sey Mou Juaupuedea Kouabuau3 pue JuapIo?V &41 Zv'ol"6 uo 38V Je &ui} ISJI} Sly 6uuanp uaxe} bulaq suolletasqo bulsanu OU 0} pal Sly} Je4} paleis sem Hi 'Jo4 Sem suoiienjasqo bulsanu si4 Jo Kouanbajy 8y} bulpuebax uoiieluxojui 24} Je4} Inq quauuuedap grV 04} uI pJeoqajiym 04} 0} peppe Sem sullio) JW Jey} uO^!b sem a3uapin] 8 'leis Kq payoeojdde uaym suoIuaNaiul pue aje? buisinu Ile pasnjau pue aNleJedoooun SeM ueueiua6 S4} Kejs s4 1noyfnoJy} Je4} 6unjou JSIIUM abeyosip 0} Joud aqejayaud uaaq 31eY pinom suoleesqo J0 Jas Jayuny e Jey} abpaimouxoe JJADMOY op # 'suoienlesqo jo Kouanbau} pue 3J02S fuuJeM Ajue3 94} punole avuepin6 Ieuoieu blOz Kuenuer 0z Kalie8 3 SW Kalloj} ay} 341 ay} Ka41 spab Io6 84} [a6 84} aseald 84} uay} bei} 186 ay}
peH eI?i] Jossojold aNnjax3 j8143 suixuar yejoqaa 'ueujie4) annbax3] j8143 ueH e13uu1 ossajold 7717Mi Kjajajuls sunoA "1u18 ajeunuojun fjauajixa S/Y} UUOJY Ue? &M buujeal JaAaJeym Bulxe} Inoqe Jsaulea JSOU al pue Kjsnouas Kjauajxa Jalleu &4} uaxe} 3EY aM Jey} nof aunsse 0} axi pinom "sn 41IM ^BY nof 1ey} senssi &4} buisieJ JO} nof xuey} Ajajaouis 0} axll pInom uollesiuebuo a41 inoybnoJy} sianal Jay1o snouea Je pue bullaaw wueeL juauuedea J8v ay1 Je passnosip uaaq sey ase? S/y} Jey} lJiuo? Ue? a8V UJ4IIM waisKs pjeoq 9114M Juajn? JO aJeme JleIS Ile apel #^EY aM 'ali} ales 34} !V bulxel uoisioap Jeap? pue uaxe} suoiioe a1ejisuouap 0} buidaax pJojaj snoauejoduajuo? J0 apueuodu ay} J0 ajeme apeu aJe Jles Ile 1eY} pajnsua ?eY a 'Jeinoiuued UI 'S1u818 8s841 J0 UollladaJ OU &q IIIM 3J341 Jey} aunsua 0} aed U! sainseau Jnd J4EY pue pauJnooo JuapIoul SI41 Jey} 1ejbaJ Yonu Kua^ ?M Jayuny e1ebilsaAUl Uk? &M Jey} OS W! a1/a38j 01 Inajeub &q pInoM &M 4leap S14 0} painquujuo? s1y} Jey} ajuapia Kue 10 Kuejluo? a41 0} ajuap1A? Kue e1EY nof Ji uolleis sasinu 04} 1e puey sseooe 0} eqe sem sulloj JW Jey} 128j1a a41 04 ajuapia Ou pUl} Uej #M Vloz Kuenuer 0z Kalieg 3 SW 84} Ia6
'apeu &q 0} pey sluaied pue JleIs 41oq 0} XSIA JO &oueieq a41 J0 Juauabpnl e ajojajayl koljod aua16fH puehi a41 Vl DIH Koilod zsnul 4HIM auil UI Wau} &sn 0} pajinbaj aJe JleJS Se 'eaue &4} WUQJ} pBAOW8I /jajaiduo? aJam sJasuadsip 'squailed Jayio JO} YSIJ aseajoui paapul pue Diisileaiun aq pinom Jey} uojuido ay} Jo Sl uoijesiuebuo &41 Sulo? JWN Jo Kquoi 941 U pOAOWaJ aJ8M sjasuadsip JSIIYM '48as ueaq bupey IenpINpul a4} Inoylm Kjaxlun suaas SI4L 'juauuuedap &4} Ul sjayjo pue uolleis a41 Je Hleis a41 0} Jueuuedap 46n014} XleM pue Sly WOJJ Jlasuly JAOWOJ 0} pey a^ey pinom &4 uolleis sasunu Je [a6 &4} ssa33e 04 sulllo) JW JQ} Jepio UI os Kep e sinoy VZ JleIs Kq pauueu S! SI4L uolleis sasinu Iemlua? WoJ} aqISM aJe sappiqno Ile Iey} seunsua Juauuedap &4} JO Ubisap 841 quauuedaa 38V &4} Jo appilu 94} S! Y214M uoljeis sasunu |ejqua? a41 J0 aje Xsap e UO 1oe} Ul aJam sullo) JW Aq peidnooo jeoiqnj a4} 01 as0p2 pavejd JOU #J8M puey paiouaj a4} Jey} Jollaq Jno sl Hl uohlels sasanu a41 lox} puey passazze a^e4 pino) suliio) WW Jay1a4m 0} se a3uapia Aopoipemhuo? SEM 9Ja41 appiqn3 .suIlIO) JW 0} asopp Kjan uohieis sasunu ay} uo pazeid a43M (1aqunu 4i 0z 1e poveullsa) sja6 puey pavjaiio? a4} Je4} uanib SEM a3uapiaa Jayuany JaaaMoH 'quaupuedap 381 a4} Woj} paijallo? Sem jasiiues puey Jey} uanis Sem a3uapia3 snoauejoduajuo? Kjajaiduuo? Jou aJe spJ03a1 buisunu a41 JeY} Ideooe &M 'a1ou uolleJS ,sesinu |eJjua? 34} Je paoeid pue paAowal aJaM eaje Jeau ui sjosuedsip 1a6 Jaslues Ile Jey} UOIJEWjojul 94} 0} esuodsal Ul sem !| Jolpop buipuane &41 01 Kuo1sly suillo? JWN 1461/46/4 pue ueId Juauabeuelu &4} 0} Jajaj O1 asunu a4} paiduojd pue pabpajmouxpe sem J! Jey} Juaunoop 0} esunu ab1ey2 e Kq paubis sem 341 'KJoJsIy Ieoipau Ised S/y YIIM Jelllle} Kan Mileinjeu aJ0jaja4} aJem Jleis (siuol 'Zl snoiaid 94} Ul as84} JO €9 YIIM |eJo} Ul SOUl} LL) Juauuedap ay} Ul Japuehe Jeinbaj uaeq pey ay Moux noa sV apeid U1 Juauabeueu e pey pue axinas &4} 0} UMOUX SeM 84y Jey} paijuapi YDI4M pJ02a1 Sly UO 6el} UOIJeuJolul Juaied Ieoi1uu? e pey Sulllo) JW Jey} Qulod 5/4} Je paiou sem H| ajuepuatle Ul asunu abe4? &41 Kq Juaussasse obe14} ay} buuunp wa1sKs piuojpoaia 38V ay1 OJul pajajua ajam sllejap sullloj JW 'Ypea1 SIY J0 }no paAOU &q 0} Jashiues puey a4} 4O} paau a4} 40 Ksdallda Isuilioj JW wnoqe 6ulp4o3au Jualedde ou SeM 81841 "atep 0} dn Idax IoU alam pue pajaiduo? Kiin} JoU aJ8M 38/ U! sa10u fuisinu 04} Je4} U9nl6 sem a3uapia3 'p 'uejd juauabeueu |eoIulp? Jay} epnpul Jou pIp inq ajuas81d s,Juailed 841 pJoJaJ 0} pasn Sem Juaupedap U! pJeoq a1lym &41 uoissiupe ,sulllo) JW JO awi} }V 'Eloz Jeqo1oo Ul paonpoJju seM S/y} 'paiou aje suoijebIsaAUl oilpads pue suoienesqO Jeinbaj Buuinbaj sluailed ajaym pleoq a3i1ou e pjajia Ui Sl YQ14m apleog a3uein Je snieis Juailed, @ Se Umoux Si Jeym sey Mou Juaupuedea Kouabuau3 pue JuapIo?V &41 Zv'ol"6 uo 38V Je &ui} ISJI} Sly 6uuanp uaxe} bulaq suolletasqo bulsanu OU 0} pal Sly} Je4} paleis sem Hi 'Jo4 Sem suoiienjasqo bulsanu si4 Jo Kouanbajy 8y} bulpuebax uoiieluxojui 24} Je4} Inq quauuuedap grV 04} uI pJeoqajiym 04} 0} peppe Sem sullio) JW Jey} uO^!b sem a3uapin] 8 'leis Kq payoeojdde uaym suoIuaNaiul pue aje? buisinu Ile pasnjau pue aNleJedoooun SeM ueueiua6 S4} Kejs s4 1noyfnoJy} Je4} 6unjou JSIIUM abeyosip 0} Joud aqejayaud uaaq 31eY pinom suoleesqo J0 Jas Jayuny e Jey} abpaimouxoe JJADMOY op # 'suoienlesqo jo Kouanbau} pue 3J02S fuuJeM Ajue3 94} punole avuepin6 Ieuoieu blOz Kuenuer 0z Kalie8 3 SW Kalloj} ay} 341 ay} Ka41 spab Io6 84} [a6 84} aseald 84} uay} bei} 186 ay}
peH eI?i] Jossojold aNnjax3 j8143 suixuar yejoqaa 'ueujie4) annbax3] j8143 ueH e13uu1 ossajold 7717Mi Kjajajuls sunoA "1u18 ajeunuojun fjauajixa S/Y} UUOJY Ue? &M buujeal JaAaJeym Bulxe} Inoqe Jsaulea JSOU al pue Kjsnouas Kjauajxa Jalleu &4} uaxe} 3EY aM Jey} nof aunsse 0} axi pinom "sn 41IM ^BY nof 1ey} senssi &4} buisieJ JO} nof xuey} Ajajaouis 0} axll pInom uollesiuebuo a41 inoybnoJy} sianal Jay1o snouea Je pue bullaaw wueeL juauuedea J8v ay1 Je passnosip uaaq sey ase? S/y} Jey} lJiuo? Ue? a8V UJ4IIM waisKs pjeoq 9114M Juajn? JO aJeme JleIS Ile apel #^EY aM 'ali} ales 34} !V bulxel uoisioap Jeap? pue uaxe} suoiioe a1ejisuouap 0} buidaax pJojaj snoauejoduajuo? J0 apueuodu ay} J0 ajeme apeu aJe Jles Ile 1eY} pajnsua ?eY a 'Jeinoiuued UI 'S1u818 8s841 J0 UollladaJ OU &q IIIM 3J341 Jey} aunsua 0} aed U! sainseau Jnd J4EY pue pauJnooo JuapIoul SI41 Jey} 1ejbaJ Yonu Kua^ ?M Jayuny e1ebilsaAUl Uk? &M Jey} OS W! a1/a38j 01 Inajeub &q pInoM &M 4leap S14 0} painquujuo? s1y} Jey} ajuapia Kue 10 Kuejluo? a41 0} ajuap1A? Kue e1EY nof Ji uolleis sasinu 04} 1e puey sseooe 0} eqe sem sulloj JW Jey} 128j1a a41 04 ajuapia Ou pUl} Uej #M Vloz Kuenuer 0z Kalieg 3 SW 84} Ia6
Sent To
- Cleveland Police
- Tees, Esk and Wear Valleys NHS Foundation Trust
Response Status
Linked responses
1 of 3
56-Day Deadline
21 Feb 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
Circumstances of the Death
1. Mr Collins was intoxicated & fully conscious when he was taken to the A&E department at James Cook University Hospital at approximately 00.45 on 9.10.12.
2. Whilst at hospital it is likely he consumed further alcohol, most likely to be in the form of alcohol hand sanitiser gel, without the knowledge of the hospital staff.
3. He was discharged from the hospital at approx. 04.30 with a reduced level of consciousness.
4. He was taken by police to 3 Farne Walk, Guisborough.
5. Shortly after his arrival at the address he slipped into unconsciousness and suffered cardio respiratory arrest.
6. Mr Collins was transported back to James Cook University Hospital arriving at approximately 06.30.
7. He passed away at the hospital later that same day.
2. Whilst at hospital it is likely he consumed further alcohol, most likely to be in the form of alcohol hand sanitiser gel, without the knowledge of the hospital staff.
3. He was discharged from the hospital at approx. 04.30 with a reduced level of consciousness.
4. He was taken by police to 3 Farne Walk, Guisborough.
5. Shortly after his arrival at the address he slipped into unconsciousness and suffered cardio respiratory arrest.
6. Mr Collins was transported back to James Cook University Hospital arriving at approximately 06.30.
7. He passed away at the hospital later that same day.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
CDI patient observations records
Vale of Leven Inquiry
Missed and inaccurate patient observations
Inaccurate and inaccessible patient records
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.