Maria Howell · Prevention of Future Deaths report

Maria Howell who died on the 28th September 2019 at Basildon University Trust Hospital, Nethermayne, Basildon, was resident in Cranham Court Nursing Home and she had a RIG tube in place. The nurse on duty noticed that the RIG tube had fallen out, but was not trained to reinsert, she delayed calling for an ambulance so the timings as to when this fell out was unknown. She was taken to Basildon A & E and at the hospital some hours later she had the PEG button reinserted and was discharged home. The same nurse was on shift that evening and Mrs Howells became unwell, around 7pm. No ambulance was called by the nurse until the day nurse came on duty, some 12 hours later. Mrs Howell was taken by ambulance where it was diagnosed that she had Peritonitis and sadly passed away on the 28th September 2019

That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical. That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention.