Linda Rose Lloyd · Prevention of Future Deaths report

On 10th January 2014 an investigation commenced into the death of Linda Rose Lloyd aged 63 years. The investigation concluded at the end of the inquest heard on 1st April and 28th August 2014.

The record of the inquest confirmed as follows:

The Medical cause of death was
Ia Acute subdural haemorrhage

The conclusion of the Coroner as to the death was Narrative conclusion as follows:

Having complained of a headache earlier that morning, on 2nd January 2014 Linda Rose Lloyd was found at her home address at 19:14 hours with a Glasgow coma score of 10/15 and unable to verbally respond to ambulance personnel. She was taken to hospital where she was triaged and assessed as being a very urgent priority. She was not assessed by a doctor until 22:12 hours and noted to have a Glasgow coma score of 7/15. A CT scan was undertaken at 01:15 hours the following morning which confirmed the presence of an acute subdural haemorrhage. She was not felt to be suitable for neurosurgical intervention and was pronounced deceased at 19:55 hours on 3rd January 2014. There was a delay in treatment which could have affected the outcome.

See the contents of section 3 above.

At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.

• During the Inquiry, I received written evidence a review has taken place further to this incident, and that it is now only the very senior paediatric nurses who are able to triage and that a triage training plan has been implemented which is to be completed by all nurses who triage and is designed to ensure all triage staff are able to assess and direct initial care for patients and ensure they are placed in the most appropriate area post triage.

• I was further informed that changes made to departmental policy have incorporated the necessity to consider the effects of patients treated with warfarin, and that A & E consultants are working to improve and implement an

However, having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:

Although encouraged by the steps being taken, I remain concerned that the procedures in place at the hospital are insufficiently robust, and that staffing levels do not provide the Trust with sufficient resilience, to enable the Trust to minimise the risks of further deaths in similar circumstances particularly given the criticisms made by the independent expert and the number of areas of concern he raises.

I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address these areas of concern.