Barbara White · Prevention of Future Deaths report

On the 04.01.2013 I commenced an investigation into the death of Barbara White date of birth 12.06.1935. The investigation concluded at the end of the inquest on 05.11.2013. The conclusion was that the deceased died as a result of Natural Causes.

On the 8th December 2012 the deceased presented to Tameside Hospital with symptoms consistent with biliary colic. She was assessed and a treatment was put in place. On the afternoon of the 9th December 2012 her clinical presentation began to deteriorate and she was reviewed by a doctor. Blood tests, x-rays and observations were requested. There was no subsequent review of tests requested, nor were any nursing observations carried out. At 6am on the 10th December when nursing observations were carried out the PARS score was incorrectly recorded and there was therefore a failure to note a significant deterioration in Mrs White’s condition. At 07.05am her PARS score was 0 and she required emergency intervention. Following this her condition deteriorated and despite extensive intervention by the Intensive Care Unit she died on the 2nd January 2013.

1. There was a lack of clinical observations for a period of 12 hours on the 9th December. In addition no nursing observations were carried out during this period of time.
2. At 6 am Mrs White’s PARS score was recorded as 2 when this should have been 5 which if correctly recorded would have led to medical intervention.
3. There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxiliary nurse who was not familiar with the Surgical Unit. This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care. However, there was a lack of escalation of this issue to the Night Nurse Practitioner.
4. There was a lack of information in the patient’s medical records following the handover from the day staff to the night staff. Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant. At the Inquest I heard evidence from Dr ████████ who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was that she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations.