Jude Augustus Gordon · Prevention of Future Deaths report

On the 1st December 2011 I commenced an investigation into the death of Jude Augustus Gordon, who was born on the 26th May 1958. The investigation concluded at the end of the inquest on the 29th August 2013. The conclusion of the inquest was that Mr Gordon died from cardio respiratory failure, due to ileus of the small intestine, due to restoration of bowel continuity due to Crohn’s Disease. Ankylosing Spondylitis was a significant contributory factor. Mr Gordon was in hospital and following a sudden deterioration in his condition, such deterioration being recognised, the level of treatment for Mr Gordon was not increased.

Mr Gordon underwent successful surgery and anaesthesia on the 23rd November 2011 and initially his recovery was uncomplicated. However, at about 0730 hours on the 27th November his condition deteriorated and there were objective signs of respiratory failure. It was recognised by staff that there was a problem, but the need to attend to that problem was not acted upon. He was not referred to more specialist care such as critical care. He went for a CT scan later that day and on returning to the ward suffered a cardiac arrest and died very shortly afterwards.

One of the objective signs of his deterioration that morning was the Early Warning Score. In the Sheffield hospitals this is referred to as the SHEWS. It is not clear whether any referral to more specialist care would have led to a different outcome for Mr Gordon. (A copy of the SHEWS Guide is enclosed).

(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system.

(2) Evidence was given at the inquest, by a consultant, that if he had been called to see Mr Gordon at the time his condition deteriorated, as was indicated by the Early Warning Score system should have happened, then he would have referred to critical care. He was not contacted. I was informed at the inquest that a Trust in Birmingham has a computerised system, that leads to an automatic alert to the relevant senior doctor on each occasion that a Early Warning Score exceeds the relevant level, for contact to be required. Such a system would on the 27th November 2011, to the consultant attending on Mr Gordon.