A coroner has demanded action by Bedford Hospital to close loopholes in procedures and training that she believes may lead to more patient deaths.
Bedfordshire and Luton assistant coroner, Amy Street, has slapped a Prevention of Future Deaths report on Bedford Hospital, following the case of a pensioner who became dizzy, fell over and fatally banged her head while being taken to the toilet.
Eighty-seven-year-old Pamela Evans died of a subdural haematoma (bleeding on the brain) on November 4, 2018, one week after the fall, in the coronary care unit, which the coroner said could NOT have been prevented.
“In my opinion, there is a risk that future deaths could occur unless action is taken,” said the coroner in her report, which was published this week. An inquest was held on July 25 this year.
The coroner said the woman also had the appropriate help from a nurse, who had accompanied her on her frame as she went to relieve herself at 3.45am. She had been under cardiac investigation for dizziness, fainting and falls but was due to be discharged the next day following the insertion of a heart beat recorder.
However, the coroner found that “despite the increasing concern of nursing staff, she was not seen by a doctor until 0600; the relevant medical team was attending a cardiac arrest and the critical care outreach team was not called.”
The coroner found a loophole in the way patients are assessed and possibly in the training of staff to deal with such incidents. Although she said in the case of Pamela Evans, medical intervention would not have changed the outcome.
In her report, the coroner said: “If the relevant medical team is busy dealing with another emergency, a patient may still face delay receiving potentially life-saving measures, even if the critical care outreach team is called.”
The coroner found a mismatch between the intention of senior nurses that staff should call the critical care team when they have concerns about a patient and the understanding of some nurses.
She said there is a lack of an audit to assess the understanding of the nurses and a lack of knowledge within the Trust of whether training has been effective.
The coroner added that, “I am therefore concerned that significant and potentially life-saving learning may be missed by the trust in the future even if serious incident investigations are carried out.”
The coroner has given the hospital until November 29 to report details of action taken or proposed to be taken, setting out the timetable for action. They can also explain why no action is proposed.
A spokesman for Bedford Hospital NHS Trust said that the hospital does not routinely comment on individual patient cases.
“In addition, certain patient cases could be undergoing investigation to respond to a Coroner’s report, in which it would be inappropriate for the hospital to make any comment about such cases during this time,” the spokesman said
Words: Local Democracy Reporter David Tooley