Rose Jean Coles
PFD Report
All Responded
Ref: 2013-0246
All 1 response received
· Deadline: 22 Nov 2013
Coroner's Concerns (AI summary)
Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
View full coroner's concerns
Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward
Responses
Action Planned
University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures. (AI summary)
University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures. (AI summary)
View full response
Dear Mrs Voisin Regulation 28 Report Ref 00231/20012 and Ref 03754/2012 Further to the recent inquests, into the deaths of Jared McDowall and Rose Coles, please find attached a composite action plan addressing the matters of concern addressed within the two Regulation 28 Reports issued to the Trust on the Ist October 2013. The Trust is confident that the actions described, many of which are already in hand, will address the concerns expressed and mitigate the risk identified of future deaths attributable to these factors_ The action plan will be monitored through the Trust's governance procedures to ensure its full implementation. Please do not hesitate to contact me if you require any further information_
Sent To
- University Hospitals Bristol NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Nov 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 23rd November 2012 commenced an investigation into the death of Rose Jean COLES, Aged month The investigation concluded at the end of the inquest on 12"h September 2013. The conclusion of the inquest was Ia Congenital heart disease (operated)
Circumstances of the Death
Rose Coles was born prematurely at 34 weeks gestation on 4ih October 2012, she had congenital heart disease and received treatment for this She died at 09.50 hours on 13"h November 2012 at the Bristol Royal Hospital for Children;
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.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
GMMH local structured risk assessment responsibility
Southport Inquiry
Poor health and social care integration
Cross-Administration Patient Safety Coordination
Infected Blood Inquiry
Poor health and social care integration
Central Delivery with Devolved Support
Infected Blood Inquiry
Poor health and social care integration
Multi-Trust Mortality Meeting Engagement
Hyponatraemia Inquiry
Poor health and social care integration
Commissioner for Survivors of Institutional Childhood Abuse (COSICA)
HIA Inquiry
Poor health and social care integration
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.