Denise Prior

Date of report	2 Jun 2014
Reference	2014-0262
Deceased	Denise Prior
Coroner	Michael Kendall
Coroner area	West Sussex
Category	Hospital Death (Clinical Procedures and medical management) related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Marianne Griffiths, Chief Executive, Western Sussex Hospitals NHS

Trust, St Richards Hospital, Spitalfield Lane, Chichester, West Sussex
PO19 6SE

1 | CORONER

Tam Michael Kendall, Assistant Coroner, for the coroner area of West Sussex

2 | CORONER'S LEGAL POWERS

I 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.

3 | INVESTIGATION and INQUEST

On 20" May 2014 I concluded the inquest into the death of Denise PRIOR,
born 18" February 1943 (aged 60 years) who died on 6" November 2013.
Mrs Prior had died as a result of (1a) Global hypoxic ischaemic injury to the
brain (1b) Hypoxia (1c) Facial injuries sustained in a witnessed fall
(29/10/13) (II) Debridement and closure of facial laceration. MUA plus oris
of fractured nasal bones. Closure of intra oral laceration (successful
30/10/13). I determined that “The deceased died from a cardiac arrest
following a fall caused by her underlying medical condition.”

4 | CIRCUMSTANCES OF THE DEATH :
Denise Prior died from the consequences of a cardiac arrest following a fall,

which in turn had been caused by her underlying medical condition.

During the inquest considerable attention was given to the concerns of Mrs
Prior's family arising from the records of Mrs Prior’s treatment at St Richards,
which is part of the West Sussex Hospitals NHS Foundation Trust. In
particular the records of her oxygen levels on 30th and 31st October 2013
were examined at length.

I heard evidence from several witnesses employed by the Trust, and
concluded that there was conflicting evidence as to the precise reason for her
cardiac arrest but no evidence to support a finding that on the balance of
probabilities her cardiac arrest had been caused by any failure by the Trust
or its employees to administer oxygen or any other treatment required by
her condition.

Nevertheless I expressed serious concerns about the standard of record-
keeping on the Middleton Ward of St Richard’s hospital. I found that the
evidence showed particularly in respect of the Patient Observation Charts
and the application of the ‘National Early Warning Score’ (‘NEWS’) system
(i) that the ‘O2 SATS’ entries had been completed in the wrong
line on four occasions on 30th October;
(ii) that the total score of Mrs Prior’s readings had been incorrectly
calculated on five occasions on 30th October;
(iii) that on three occasions on 30th October the patient's total
‘NEWS’ score amounted to 5, while individual scores of her oxygen
levels were at ‘3’ on one occasion on 30th October, and that
according to the notes about the ‘NEWS’ system any total of 5 or
individual score of 3 required monitoring to be increased in frequency
“to a minimum of 1 hourly” and for a “trained nurse to urgently
inform the medical team caring for the patient” and for an “urgent
assessment within 1 hour by a clinician with core competencies to
assess acutely ill patients.” There was no record that these steps
were taken nor of the outcome, nor alternatively that any reasons
existed why they should not be taken, nor that any assessment had
been made that Mrs Prior’s “normal parameters” would have allowed
a more relaxed monitoring regime or application of the ‘NEWS’
system;
(iv) that while nurses were expected to use their experience in
assessing the condition of patients and the course of action required,
including any departure from the ‘NEWS’ system, the observation
charts did not include any written record of such an assessment
having been made, nor any cross-reference to any other records that
might suggest that alternative courses of action were justified;
(v) that the Prescription and Administration charts contained no
record of oxygen being prescribed nor of the level of such
prescription;
(vi) that while supplementary evidence was given that steps had
already been taken to introduce a computerised ‘Patient Track’ record
system in the previous 2 years, and that such a system would ensure
that observations were recorded correctly and that ‘NEWS’ score
totals and alerts would be correctly indicated, that system had not
been working on 30th and 31st October and on other occasions,
during which the paper records already referred to were used
instead, and would be used again in the future during any
breakdown; moreover the computerised system did not in any event
record the prescription of oxygen levels, and an oxygen
administration audit had not yet been commissioned.

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. -

That there is a risk of other deaths occurring in the future from the
inadequacy of record-keeping practices at St Richards Hospital in the
recording of oxygen levels and its prescription, and in the application or
departure from the ‘NEWS’ system.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe
you 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 28" July 2014. I, 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

I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:

BE 2usnter of the deceased)

Iam 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.

DATE:02 June 2014 | NED : Michael Kendall, Assistant Coroner

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Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Western Sussex Hospitals NHS Trust (PDF)

Our Ref: MG/CS/KLG/PRIOR
28 July 2014

Mr M Kendall

Assistant Coroner for West Sussex

County Record Office
Orchard Street
Chichester

West Sussex

PO19 1DD

Dear Mr Kendall

Western Sussex Hospitals INHS|

NHS Foundation Trust

NECEIVE

29 JUL 2014

St Richard’s Hospital
Spitalfield Lane
Chichester

West Sussex

PO19 6SE

Tel: 01243 788122
Fax: 01243 531269
www.westernsussexhospitals.nhs.uk

Ce@eesssannann

RE: Inquest into the death of Denise PRIOR — Regulation 28 response

Thank you for your letter dated 3 June 2014.

The Trust has undertaken a thorough investigation and review into the areas in which you raised
concern and is pleased to enclose an action log setting out the action taken.

| hope that you will be reassured by the actions taken by the Trust and please do not hesitate to
contact me should you require any further information or clarification.

Yours sincerely

Marianne Griffiths
Chief Executive

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