Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0274, written 24 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2013 |
|---|---|
| Reference | 2013-0274 |
| Deceased | Harold Elvidge |
| Coroner | Heidi Connor |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Nottingham University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive, Nottingham University Hospitals NHS Trust
CORONER
| am HEIDI CONNOR, assistant coroner for the coroner area of Nottinghamshire.
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
| concluded an inquest into Mr Harold Elvidge (DoB 22.10.33 ; DoD 2.11.12) on 24"
October 2013. | recorded a verdict of accidental death.
CIRCUMSTANCES OF THE DEATH
(1) It was clear in evidence that a Staff Nurse on the Critcal Care Unit at Nottingham
City Hospital had, on 6 October 2012, used the wrong type of fluid bag to keep an
arterial line open. She used 5% dextrose instead of normal saline. This error was
realised before Mr Elvidge died, and is consistent with the Trust's own SU! report.
Mr Elvidge’s blood sugar levels were misinterpreted as a result of this error, and
drugs administered accordingly, resulting in brain damage, and his subsequent
death, on 2" November 2012.
| heard evidence during the inquest about changes made in the Critical Care Unit
following Mr Elvidge's death, particularly in relation to how fluid bags are stored,
with a view to reducing the risk of different types of fluid being confused.
The evidence of the Staff Nurse in question was that the two types of fluid (in the
500ml bags required for this purpose) were stored adjacent to each other in a fluid
room / cupboard, as well as being available in the Omnicell cabinet. The nurse
obtained the fluid from the fluid room/cupboard, rather than from the Omnicell
cabinet. If she had obtained this from the Omnicell cabinet, she would have been
prompted to confirm what fluid bag she intended to take out, and it is likely that the
error would not have occurred.
(2
~~
(3
=
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
(1) {tis clear that much work has been done by the Adult Critical Care team to learn
from the mistakes made in this case. It is now not possible to obtain 500 ml
bags of 5% dextrose fluid without the input of a pharmacist, and they are not
stored in the same place as 500ml bags of normal saline. | also heard about
further training, and that sharing of these events has taken place.
(2) The evidence suggested that Omnicell cabinets may be available soon in E12 at
the QMC. It was however clear that, although Critical Care at the City campus
has Omnicell cabinets in place, this is not the case across the trust, nor even all
all critical care areas in the trust. While a mistake in the context of intensive care
and arterial lines may be more serious for some patients, there could be equally
catastrophic outcomes for patients in non critical care settings, if there remains a
risk of different types of fluids being mixed up.
(3) Whilst mindful of the cost implications involved, | am concerned about the risk of
future deaths occurring in other parts of the trust which may not have as robust
a safety standard as Critical Care (certainly at the City Hospital campus) now
appears to have.
(4) Itis not for me to make specific recommendations regarding the purchase of
specified equipment, but a trust-wide review of policies for safe storage of
different types of fluids would reduce the risk of a similar tragedy occurring in
future. This would include issues such as where these fluids are stored, how
they are packaged and labelled, who is entitled to change bags, what checks
are in place, and how this is recorded.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and the
Trust have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 19" December 2013. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner. | am also under a duty to send the
Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
24" OCTOBER 2013 ee Gn
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