“6 A lack of clarity about if and when NIV can be offered to admitted patients”

The coroner’s concerns

6 A lack of clarity about if and when NIV can be offered to admitted patients. A patient admitted into RCHT with a respiratory element to her underlying condition was not brought to the attention of the respiratory team. The presenting complaint was not of a respiratory nature and so the challenge appears to be to identify those patients with multiple co-morbidities, one of which has a respiratory component, particularly where the patient is not on a respiratory ward. A failure to recognise a deterioration in the presentation of a patient which could have triggered a request for repeat bloods and revealed the worsening acidosis before an AKI developed. There appear at least two elements to this: i) the use of food and fluid charts to make sure a patient is not becoming dehydrated and is having adequate calorific intake; ii) for patients who stay on AMU longer than usual, ensuring there is some continuity in medical or nursing care, so a deterioration in presentation can be recognised promptly. Would there be value, for example, in requiring a patient who is on AMU for longer than say, 48 hours, to become the responsibility of a single, named consultant who will be responsible for regular review starting at the 48 hour mark?

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, 2023-0032

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