Mary WALDRON · Prevention of Future Deaths report

Mary WALDRON died on 24 August 2013, aged 76 years old. An investigation into her death was successfully started, as ordered by the Chief Coroner. The investigation concluded at the end of the inquest on 23 December 2013. The conclusion of the inquest was narrative ████████

Mary Waldron died on 24 August 2013 at University Hospital, Coventry, having been transferred from St Mary's Nursing Home that morning. She had been a resident of the nursing home since 19 August and had become unwell at approximately 6.30am on the 24th. Following an episode of vomiting a nurse ████████ requested an out-of-hours GP visit. Observations were taken by that nurse only after an initial phone call to the GP service. A low blood pressure was recorded. This observation was reported to the out-of-hours triage nurse in a subsequent telephone conversation. A GP visit, rather than an emergency ambulance request, was arranged as a consequence of the discussion between the triage nurse and nursing home nurse.

An ambulance was urgently requested only after the attendance of the out-of-hours GP. During transfer from the nursing home to hospital, Mary Waldron suffered a cardiac arrest. Only basic life support was undertaken as no venous access could be obtained. There was confusion between the ambulance driver and paramedic as to how long the transfer to hospital would take, following the cardiac arrest. The driver reported a time of 15 minutes; the paramedic understood the transfer time to be 5 minutes. Basic life support was continued until arrival at the hospital, where death was pronounced. On the evidence of the paramedic, he would have made the same decision (to continue with the basic life support and onwards transfer) had he known the correct transfer time.

(1) failure of the nursing home staff to recognise an acutely unwell resident;
(2) failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure;
(3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents; with reliance solely on initial nursing training;
(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition;
(5) inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed, when evidence given at the inquest was that this was not the case;
(6) lack of clarity as to the investigation that is to be undertaken by the CQC. The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing;
(7) the nurse primarily involved in this incident is no longer an employee at St Mary's and is working elsewhere. St Mary's nursing home is therefore unable to take action to address potential future risks relating to the training of this nurse;
(8) the potential for further incidents of confusion between driver and paramedic with regard to hospital transfer times, with the possibility of significant adverse consequences. Evidence given was that satellite navigation information (including time to arrival) was only available directly to the ambulance driver. Direct visualisation of a satellite navigation console by the non-driving paramedic could address this risk.