Peter DORNEY · Prevention of Future Deaths report

On 15th April 2014 I commenced an investigation into the death of Peter DORNEY, Aged 64. The investigation concluded at the end of the inquest on 14th November 2014.

The conclusion of the inquest was a narrative which read as follows

Peter Dorney had a complex medical history. He was in hospital and unwell. Overnight on the 3rd/4th April 2014 he deteriorated; increased observations were not carried out and a senior member of staff was not notified as they should have been; this resulted in the lost opportunity to render medical care and treatment. He died on 4th April due to bronchopneumonia

The medical cause of death was recorded as:

Ia Bronchopneumonia
II Alcoholic liver disease

Peter Dorney was admitted into Frenchay Hospital on 29th March, during his admission it was clear that he was not a well man. During the ward round on 3rd April there was no evidence at that time of a chest infection. Overnight on 3rd/4th April the nurse caring for Peter Dorney said that at 02:00 hours his EWS score was 2 due to his low oxygen saturations. This score of 2 should have resulted in her informing the nurse in charge and increasing his observations to hourly. In evidence she said that it was her intention to do both of these things and that she should have but she didn't.

When Peter Dorney's observations were carried out at 07:40 hours on 4th April he was now very unwell and his EWS was 5. Appropriate action was then taken however later that he suffered a cardiac arrest and died.

During the evidence the ward sister gave evidence and she was of the opinion that there should be mandatory training on EWS for nurses. It was clear in the evidence that the protocol in relation to the EWS score was not followed and I was told that the EWS training was not mandatory currently. This case highlights why EWS scores are so important to the well-being of patients