Roy Burgess · Prevention of Future Deaths report

On 13/12/2017 I commenced an investigation into the death of Roy Burgess, 87. The investigation concluded at the end of the inquest on Wednesday 21 November 2018. The conclusion of the inquest was a Narrative conclusion as follows:

Mr Burgess underwent surgery at Doncaster Royal Infirmary on the 3rd December 2017 to repair a fracture to his left neck of femur which he sustained in a fall at his home on the 1st December 2017.

Post operatively, there were missed opportunities to identify and escalate Mr Burgess’s deteriorating condition prior to his death. However it is unlikely that any such interventions would have altered the outcome.

Mr Burgess was taken to Bassetlaw Hospital on the 1st December 2017 having suffered a fall in the garden of his home. He was transferred to Doncaster Royal Infirmary on the 2nd December 2017 and he remained there until his death. Cause of death :

I (a) Left femoral fracture (treated) and Ischaemic heart disease

(b) Coronary artery atheroma

II Advanced age

(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess’s care to receive Senior Medical reviews which could have altered his management.

(2) Inadequate record keeping by clinician within the Clinical notes. There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes, e.g. on 4th December 2017, Mr Burgess’s care was escalated between 11:40 hours and 16:30 hours on at least 5 occasions and no entries were placed in his clinical records. This could have had a detrimental effect on his care and if this practice continues it will potentially affect other patients.

(3) Finally, untimed dictated notes of ward rounds, were then entered into the records in a non-chronological order, which was unhelpful and potentially misleading