DCSIMG

Monitoring system scrutinised after Chichester mother died

St Richard's Hospital

Picture by Louise Adams C140028-3 Chi St Richard's Hospital ENGSUS00120140113154234

St Richard's Hospital Picture by Louise Adams C140028-3 Chi St Richard's Hospital ENGSUS00120140113154234

A MOTHER’s death in hospital has led a coroner to examine a patient monitoring system.

Denise Prior, 60, of Sherbourne Road, Chichester was admitted to accident and emergency in October last year after falling down a flight of stairs.

Mrs Prior’s condition deteriorated after an operation and she died following a heart attack in St Richard’s Hospital, Chichester, a week later.

An inquest into her death, held at Edes House, Chichester, on Tuesday, revealed Mrs Prior suffered with a neurological condition which affected her movement and speech.

But her care on Middleton Ward was scrutinised by deputy assistant coroner Martin Milward after mistakes were made in calculating Mrs Prior’s MEWS score. The score, which is normally worked out by an online system called Patientrack, determines how ill the patient is.

Sheila Riches, representing Mrs Prior’s family, questioned how ‘seven out of 12’ scores could be miscalculated by ‘experienced nurses’.

But it was revealed the system ‘wasn’t working’ on the day because of the poor WIFI connection – making nurses ‘revert to hand-written observations’.

Mr Milward said: “Failures of this system will continue to exist in the future as long as paper records are used.”

The inquest also sheds light on Mrs Prior’s oxygen levels which had been recorded as low as 83 per cent during her time in hospital – a good reading is 95 per cent and above.

The reading prompted Mrs Prior’s family to question whether she died of respiratory failure.

Giving evidence, Dr Andrew Kendall said Mrs Prior was ‘profoundly hypoxemic’ – indicating a low level of oxygen. However a prescription of oxygen was not documented on Mrs Prior’s notes. Medics debated whether the cardiac arrest had been caused by a pulmonary embolism, caused by a blood clot, or hypoxia, which would have created breathing difficulties.

However, Mr Milward said: “Mrs Prior was seen at 12.30am and both nurses are clear that there was nothing in her movement to give suggestion that she was suffering from respiratory failure. Respiratory failure may have contributed to her death but I can’t be sure it did.”

Recording a narrative verdict, he said: “Mrs Prior died from cardiac arrest following a fall caused by her underlying medical condition.”

He said he would write a report to prevent the risk of further death, based on the findings of the inquest.

“The NHS should give urgent consideration to the element of oxygen in the system and should deal with the WIFI at the earliest opportunity.”

Denise Farmer, director of organisational development and leadership at Western Sussex Hospitals NHS Foundation Trust, said: “The Patientrack monitoring system in use in our hospitals has significantly improved the safety of patients on our wards.” She said the back-up processes were ‘constantly reviewed’ and electronic prescribing being introduced later in the year would also improve safety.

 

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