“During the inquest evidence was heard that: i”
Dated 5 Jun 2018, from the coroner for Dorset. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 31 Jul 2018.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated5 Jun 2018
- Deadline31 Jul 2018
- Published on judiciary.uk8 Jul 2018
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Dorset County Hospital NHS Foundation TrustNamed in the report as “Dorset County Hospital” | Response publishedPublished on judiciary.uk in July 2018. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
1. During the inquest evidence was heard that: i. Venous blood gases were not measured on the second admission (25'" December to 30" December), in accordance with the Sepsis Six Pathway. There appeared to be no reminder system in place to address this omission. I heard evidence that measuring the carbon dioxide levels would have assisted in determining whether the high flow machine was providing the level of respiratory support Mrs Scott required. ii. There were initially no means to provide PEEP to a patient that was deemed to need it, due to all machines being in use, or there simply being no machine in respiratory medicine. 2. Ihave concerns with regard to the following: i. Due to the lack of a reminder system in relation to measuring venous blood gases it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BiPAP or CPAP. I request that a review is undertaken to assess whether there should be a system installed to ensure the staff caring for patients where venous blood gases should have been measured are “reminded” of the need to do so. ii. | The insufficient number of machines to provide PEEP to patients who require it.
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, 2018-0172
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use