Frederick Sutton · Prevention of Future Deaths report

On 9th February 2015 I commenced an investigation into the death of Frederick Sutton dob 13th September 1930. The investigation concluded on the 14th July 2015 and the conclusion was one of Accidental death. The medical cause of death was 1a Myocardial Infarction 1b Coronary Artery Atheroma 11. Fractured right hip (Traumatic)

On the 3rd February 2015 at his home address he fell and broke his hip. He may have suffered a myocardial infarction at the same time. He was admitted to hospital and died approximately 12 hours later.

(1) The staffing levels in the hospital during his stay seemed to be less than optimal.
(2) Whilst there is a procedure for escalation of the shortage of staff, this was either not fully understood or not properly put into effect.
(3) There was clear evidence that a nurse had failed to read (or read properly) the nursing notes.
(4) The computerised note keeping system used in the Emergency Department is not able to “talk to” the system which covers the rest of the hospital.
(5) The patient required the administration of cyclizane and there was an obvious problem with the (lack of) training of the staff in this regard.
(6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to.
(7) There seemed to be a lack of training amongst the staff as to the administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery.
(8) There was a general lack of care as to the accuracy of the information held by the hospital as to next-of-kin details, where the wife of the deceased was shown as n.o.k when in fact she had died in 2008.