Susan Jill Hammond
PFD Report
All Responded
Ref: 2013-0286
All 1 response received
· Deadline: 30 Dec 2013
Coroner's Concerns (AI summary)
Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.
View full coroner's concerns
_ _ [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Although there were written warnings of Mrs Hammond's on hospital documentation they appear not to be have been noticed by the nurse who administered augmentin. In an effort to highlight the fact that a patient has an feel that there needs to be a much clearer indication on the file that the patient has such an allergy: At the inquest, it was suggested that a different coloured file should be used for any patient allergy allergy who has an allergy. Alternatively, a large sticker on the front of the file warning of the allergy would assist.
(2) It appears that when Mrs Hammond transferred from the A&E unit to the EAU she was accompanied by a nurse who had little knowledge of Mrs Hammond's condition. As a consequence no discussion took place at the handover regarding the nature of Mrs Hammond's to penicillin. It is felt that if the nurse who had cared for Mrs Hammond in the A&E department had personally accompanied her to the EAU this would have enabled a more productive handover and would have given an opportunity for discussion regarding the Although appreciate there may be practical difficulties would suggest that in future the nurse who has provided care for the patient in A&E should always accompany the patient to the EAU department in order that constructive handover can take place_ (3) Your representative at the inquest hearing was not clear as to whether the doctor involved in this case was going to be referred to the General Medical Council and the nurse who administered Augmentin was going to be referred to the Nursing & Midwifery Council it was agreed that he would inform me of this within 14 days of conclusion of the inquest:
(2) It appears that when Mrs Hammond transferred from the A&E unit to the EAU she was accompanied by a nurse who had little knowledge of Mrs Hammond's condition. As a consequence no discussion took place at the handover regarding the nature of Mrs Hammond's to penicillin. It is felt that if the nurse who had cared for Mrs Hammond in the A&E department had personally accompanied her to the EAU this would have enabled a more productive handover and would have given an opportunity for discussion regarding the Although appreciate there may be practical difficulties would suggest that in future the nurse who has provided care for the patient in A&E should always accompany the patient to the EAU department in order that constructive handover can take place_ (3) Your representative at the inquest hearing was not clear as to whether the doctor involved in this case was going to be referred to the General Medical Council and the nurse who administered Augmentin was going to be referred to the Nursing & Midwifery Council it was agreed that he would inform me of this within 14 days of conclusion of the inquest:
Responses
Action Taken
United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between A&E and MEAU, and reviewed the nurse's practice involved in the incident, providing further training and competence assessment. (AI summary)
United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between A&E and MEAU, and reviewed the nurse's practice involved in the incident, providing further training and competence assessment. (AI summary)
View full response
Dear "drug
Modification of the prescription chart to state "Drug allergies and sensitivities" in a red coloured with more space to list drugs and the effects, with the source of information and completion signature_ name and date Allergy section on prescription chart before: Chart No. 2 3 5 0 Ins DRUG SENSIIVITIES No AKPA Source PHTOT 1 V QTHER INFORMATION Pa DV Patl Kn Height cm End Weight 6 ka pre= BM 37 SA Sig Aft Allergy section on prescription chart after: Enei3 Cer ORuG AlLerGies JcC sensitivities fatt Beeops allergieS sensitivines: bck box 5ot5 NEoA F7CT akn (Clcle) hurtht Hore Geher [697 Ez
2) The handover of care from A&E to MEAU is now based on a handover tool, called SBAR This is an acronym for Situation, Background Assessment and Recommendation and allows for a structured handover to take place. This approach brings consistency in communicating points of information: Within the background section is a prompt sheet for highlighting allergies SBAR has been found to improve communications between members in different clinical areas ie A&E Vs wards_
3) has been referred to the General Medical Council
4) The Trust's Interim Director of Nursing has reviewed the professional conduct and implications in relation to the registered nurse involved. This included reviewing the available information from the time of the event in 2009. At the time of the event in 2009, the nurse's practice and competence in administration of Chairman: Paul Richardson MINDFUL Chief Executive: Jane Lewington EMPLOYER title , JonA key Abou; "jAdLt9
medicine was reviewed and a training update undertaken. Since that time, the nurse's practice has been without any further incident: Following the inquest; the nurse's practice was further considered and taking into account the impact of the inquest on the nurse she was restricted from involvement in medicines administration for a short period of time to protect both patients and herself. She has since received further training and competence assessment; which she passed without concern: With reference to your query about referral to professional regulators, the Interim Director of Nursing can confirm that she has discussed this case in detail with Nursing and Midwifery Council. This discussion included reference to actions already taken by the Trust. The discussion concluded with the Council's confirmation that will review the case_ If you require any further information, would be to liaise with you directly.
Modification of the prescription chart to state "Drug allergies and sensitivities" in a red coloured with more space to list drugs and the effects, with the source of information and completion signature_ name and date Allergy section on prescription chart before: Chart No. 2 3 5 0 Ins DRUG SENSIIVITIES No AKPA Source PHTOT 1 V QTHER INFORMATION Pa DV Patl Kn Height cm End Weight 6 ka pre= BM 37 SA Sig Aft Allergy section on prescription chart after: Enei3 Cer ORuG AlLerGies JcC sensitivities fatt Beeops allergieS sensitivines: bck box 5ot5 NEoA F7CT akn (Clcle) hurtht Hore Geher [697 Ez
2) The handover of care from A&E to MEAU is now based on a handover tool, called SBAR This is an acronym for Situation, Background Assessment and Recommendation and allows for a structured handover to take place. This approach brings consistency in communicating points of information: Within the background section is a prompt sheet for highlighting allergies SBAR has been found to improve communications between members in different clinical areas ie A&E Vs wards_
3) has been referred to the General Medical Council
4) The Trust's Interim Director of Nursing has reviewed the professional conduct and implications in relation to the registered nurse involved. This included reviewing the available information from the time of the event in 2009. At the time of the event in 2009, the nurse's practice and competence in administration of Chairman: Paul Richardson MINDFUL Chief Executive: Jane Lewington EMPLOYER title , JonA key Abou; "jAdLt9
medicine was reviewed and a training update undertaken. Since that time, the nurse's practice has been without any further incident: Following the inquest; the nurse's practice was further considered and taking into account the impact of the inquest on the nurse she was restricted from involvement in medicines administration for a short period of time to protect both patients and herself. She has since received further training and competence assessment; which she passed without concern: With reference to your query about referral to professional regulators, the Interim Director of Nursing can confirm that she has discussed this case in detail with Nursing and Midwifery Council. This discussion included reference to actions already taken by the Trust. The discussion concluded with the Council's confirmation that will review the case_ If you require any further information, would be to liaise with you directly.
Sent To
- United Lincolnshire Hospital Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Dec 2013
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 3 July 2009 / commenced an investigation into the death of Susan Jill Hammond aged 65 years. The investigation concluded at the end of the inquest on 30 October 2013 The cause of death was Anaphylactic reaction to the administration of intravenous augmentin: A narrative conclusion was given Mrs Hammond suffered a known allergy to penicillin despite this on 3 July 2009 a doctor prescribed augmentin (which is a penicillin based drug) This was administered to Mrs Hammond by an experienced nurse. A few minutes later Mrs Hammond suffered a cardiac arrest and despite attempts to resuscitate her she died at 0410 hours on 3 July 2009.
Circumstances of the Death
In both 1992 and 2002 Mrs Hammond had been administered penicillin and had suffered Anaphylactic reactions on both occasions Prior to her death Mrs Hammond was living in a nursing home She became ill and was admitted to the Accident and Emergency department of Lincoln County Hospital on 2 July 2009. Despite the fact that there were a considerable number of warnings on the documents sent by the nursing home, documents within the hospital and the fact that Mrs Hammond was wearing a red allergy warning bracelet she was administered augmentin (being a penicillin based drug) she suffered a cardiac arrest and despite attempts to resuscitate her she died.
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.