Jessica Ashton-Pyatt
PFD Report
Historic (No Identified Response)
Ref: 2013-0200
Coroner's Concerns (AI summary)
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
View full coroner's concerns
_ The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation was not charged and no defibrillation pads were available.
Sent To
- United Lincolnshire Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
24 Oct 2013
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 2nd November 2012 ! commenced an investigation into the death of Jessica Florence Ashton-Pyatt, Age 14. The investigation concluded at the end of the inquest on 30"h August 2013 The conclusion of the inquest was spontaneous rupture of the stomach of uncertain cause; verdict was natural causes
Circumstances of the Death
On 28th October 2012 Jessica became acutely unwell. On admission to the Accident and Emergency Unit at Pilgrim Hospital she was in extremis. Resuscitation attempts were unsuccessful. Post mortem showed her cause of death to be a ruptured stomach of uncertain, but natural cause
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. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk bay initially
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Majesty's Senior Coroner for South_Lincolnshire
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Majesty's Senior Coroner for South_Lincolnshire
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.