“During the Inquest evidence was heard that:- i”

The coroner’s concerns

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1. During the Inquest evidence was heard that:- i. The telephone number on the card given to the deceased when she was discharged from the Hospital related to appointments only but the purpose of the number is ambiguous and when the deceased’s husband telephoned the number on the card in the early hours of the 20" October 2016 he believed he was speaking to the Emergency Department, particularly in view of the fact that he was given advice to give paracetamol to the deceased. Evidence was given at the Inquest that the appointment card was the only documentation given to the deceased when she was discharged and the card does not have any information as to the action to be taken if there is a deterioration in a patient’s condition after discharge. The evidence given ‘by a a Consultant in Emergency Medicine at the Hospital was that if there is a deterioration in condition the patient should not be given treatment advice by telephone and the_patient should be advised to telephone 111 or return to the Hospital but accepted that there is no reference to such action on the card. ii. The telephone call from the deceased’s husband to the Hospital in the early hours of the 20 October 2016 and the advice to give paracetamol was not recorded in any Hospital records. Furthermore, the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was 2. cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased. The evidence at the Inquest indicated that the nurse would not be expected to make a note relating to the above information but she would be expected to mention the information to the Doctor. po commented in his evidence that there had been a “gross miscommunication” in the care of Mrs Forshaw. Lima accepted that, having heard the evidence of the family at the Inquest, routine observations (pulse, blood pressure, respiratory rate, temperature) and blood investigations should have been conducted when the deceased presented to the Out Patient appointment on the 21* October 2016. IMM gave evidence that there had been some discussion between Consultants in the Emergency Department and there was mention that there should be a policy for checking routine observations in patients attending Clinic for wound review, particularly where there was an indication of infection. However IEIElconfirmed that there was no formal policy in place. iv. The evidence at the Inquest confirmed that there had been a discussion between Consultants in the Emergency Department in relation to the treatment and care of Mrs Forshaw but the treatment and care of Mrs Forshaw had not been escalated as a formal report for consideration of a Serious Incident Review. Accordingly, a Serious Incident Review had not taken place in relation to Mrs Forshaw’s death, although it was accepted that, in retrospect, a Review should have taken place to enable any recommendations to be formalised within the Governance framework. I request you to conduct a review of the policies, procedures and protocols in relation to the following matters: - i. The information on the appointment cards, particularly in relation to the identification of unambiguous telephone numbers together with advice as to the action to be taken when a patient deteriorates with consideration of “telephone 111 or return to the Hospital”. ii. The notes to be recorded by Nurses, either in relation to telephone calls made to the Hospital by or on behalf of a discharged patient or in relation to Nurses conducting a preliminary examination prior to consultation with a Doctor to ensure that the notes are available to the Doctor when the Doctor conducts an examination and an assessment. iii, Routine observations and blood investigations in relation to patients attending the Hospital, particularly the Emergency Department or Out Patient Clinic, where there is evidence and diagnosis of a wound infection. v. The reporting and escalation of incidents in the Emergency Department leading to consideration of a Serious Incident Review and appropriate action within the Governance framework.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0262

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0