Royal Blackburn asked to review triage procedures

Blackburn Citizen: Royal Blackburn asked to review triage procedures Royal Blackburn asked to review triage procedures

THE Royal Blackburn Hospital has been asked to review its triage procedures following the death of a woman who was sent to the urgent care centre, rather than to A&E.
Shirley Banks, 67, who lived in Constable Avenue, Burnley had been diagnosed with cancer of the oesophagus and was undergoing chemotherapy when she was taken to hospital as an emergency admission, an inquest heard.
But a spokeman for the Hospital Trust has disputed the inquest’s findings and said Mrs Banks had been taken to A&E and treated appropriately, before being sent to the intensive care unit.
The inquest at Blackburn coroner’s court heard that Mrs Banks had a 50 per cent chance of surviving the cancer, but died after developing an infection.
The hearing was told that Mrs Banks was taken to the Royal Blackburn Hospital by ambulance on New Year’s Eve last year after becoming unwell.
However rather than being taken to the emergency department she was taken to the urgent care centre, which was not adequately equipped to treat her, and Mrs Banks died the following day.
Recording a narrative verdict, Blackburn coroner Michael Singleton said that the medical cause of death was neutropenic sepsis.
Mr Singleton said he would be making a report to East Lancashire NHS Hospitals Trust relating to the triage of patients suffering from cancer.
He said: “I am required to make a report where I believe there remains a risk of further fatalities.
“Clearly those patients should be directed to A&E, not the Urgent Care Centre, where there are not protocols in place for treatment to be be provided.”
Speaking after the hearing, Mrs Banks’ sister June Rosser said: “We hope that some good comes out of this.
“We understand the failures in the system and we hope that noone else goes through what we’ve just gone through in the past six months.
Her brother-in-law John Rosser added: “Triage procedures need to be changed, there was obviously a mistake.
“She should have been sent direct for emergency treatment, as our doctor, Dr Tattersall had requested.”
But Dr Ian Stanley, Acting Medical Director at East Lancashire Hospitals NHS Trust, said: “The trust offers its sincere condolences to the family of Mrs Banks on their sad loss. However, we feel strongly that we did everything that we could possibly do for Mrs Banks and her care she received was timely and appropriate.
“Mrs Banks was admitted to the Emergency Department at the Royal Blackburn Hospital.
“She was seen by a Consultant in Emergency Medicine and treated with IV antibiotics within 34 minutes. Her case was discussed with a specialist cancer doctor in Preston and she was then admitted directly to the Intensive Care Unit where, despite all treatment delivered by our specialist team here, she did not recover and sadly died.”

After being made aware of Dr Stanley’s comments, Michael Singleton said: “I heard the evidence, made an assement based on that evidence, and reached a conclusion.”

Comments (10)

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11:25am Sat 5 Jul 14

Lancs Away says...

How long has this hospital been open, heard nothing but bad....
How long has this hospital been open, heard nothing but bad.... Lancs Away
  • Score: 14

11:28am Sat 5 Jul 14

Fire Fly says...

Regardless of where this Lady was initially taken, she was seen by a Consultant, not a Junior (which most are ), & received the appropriate treatment within 34 minutes of arrival, a discussion was had with an Oncologist & was taken to intensive care. Sadly, I can't see how anything barr a miracle, was going to change the outcome in this case.

This hospital has it's failings but for them to come out & directly question the Coroners findings....they will be **** sure of their facts & the Coroners weak response to the hospitals statement says it all.

He's clutching at straws here to say other people are at risk because there aren't protocols in place in UCC to treat these patients...I accept UCC is not A&E but for argument sake lets say she definitely went to UCC - she still received a Consultant review & appropriate treatment within 34mins of arrival....you cannot insist that 'something' isn't working in the existing triage system when the facts clearly show it is, if not then this Lady wouldn't not have been seen so quickly & the seriousness of her situation picked up.
Regardless of where this Lady was initially taken, she was seen by a Consultant, not a Junior (which most are ), & received the appropriate treatment within 34 minutes of arrival, a discussion was had with an Oncologist & was taken to intensive care. Sadly, I can't see how anything barr a miracle, was going to change the outcome in this case. This hospital has it's failings but for them to come out & directly question the Coroners findings....they will be **** sure of their facts & the Coroners weak response to the hospitals statement says it all. He's clutching at straws here to say other people are at risk because there aren't protocols in place in UCC to treat these patients...I accept UCC is not A&E but for argument sake lets say she definitely went to UCC - she still received a Consultant review & appropriate treatment within 34mins of arrival....you cannot insist that 'something' isn't working in the existing triage system when the facts clearly show it is, if not then this Lady wouldn't not have been seen so quickly & the seriousness of her situation picked up. Fire Fly
  • Score: 10

12:37pm Sat 5 Jul 14

woolywords says...

Fire Fly,
With the best will in the world, I cannot agree with your assumptions and having re-read the article to assure myself of the events and the timeline, I offer a differing view.
The lady is taken ill, above her existing condition and a Doctor is called to see her and in his opinion, she requires being taken to hospital immediately for a particular kind of care. The question then arises; why wasn't his wishes complied with, by the ambulance crew and who directed them to UCC?
Upon arrival, it is stated that 34 minutes elapse before the correct treatment is given and given the constraints of the 'Golden Hour', for a positive outcome to treatment, where do these 34 minutes lay?
...
When a Coroner gives a narrative verdict it is because he cannot quite put his finger on exactly what the cause of death is, apart from the underlying condition. He has to draw a conclusion from the sequence of events and it seems as though, A+B+C+D+E were such that he can only conclude that each, to a greater or lesser degree, have contributed to the outcome. If he feels that certain procedures weren't followed then he will raise concerns with those whom must shoulder the blame.
In this case, the hospital has decided to publicly defend itself, instead of creating a peer review panel, to see if there could have been a more positive outcome.
...
You have to bear in mind that Coroner, Michael Singleton, has in the past, raised concerns about the procedures and treatments that patients receive at BRH, so instead of writing privately, he has made a statement in open court, where he has raised his concerns, again. The hospital, for it's part, has made an open reply, I assume, sensing a slight whiff of litigation in the air, so as to allay anyone's mounting concerns over how you are treated there. (Perhaps my comments of, St Elsewhere, are being read.)
In closing, let me state that this ladies already compromised immune system because of Chemotherapy, may have contributed to the speed of her illness but at the same time, it is apparent to me, from this article, that a more timely intervention procedure, in the correct setting, just may have had made a difference.
We may never know, as long as the hospital staff don't conduct a proper and full investigation into the circumstances. My condolences to all concerned, goes without saying.
Fire Fly, With the best will in the world, I cannot agree with your assumptions and having re-read the article to assure myself of the events and the timeline, I offer a differing view. The lady is taken ill, above her existing condition and a Doctor is called to see her and in his opinion, she requires being taken to hospital immediately for a particular kind of care. The question then arises; why wasn't his wishes complied with, by the ambulance crew and who directed them to UCC? Upon arrival, it is stated that 34 minutes elapse before the correct treatment is given and given the constraints of the 'Golden Hour', for a positive outcome to treatment, where do these 34 minutes lay? ... When a Coroner gives a narrative verdict it is because he cannot quite put his finger on exactly what the cause of death is, apart from the underlying condition. He has to draw a conclusion from the sequence of events and it seems as though, A+B+C+D+E were such that he can only conclude that each, to a greater or lesser degree, have contributed to the outcome. If he feels that certain procedures weren't followed then he will raise concerns with those whom must shoulder the blame. In this case, the hospital has decided to publicly defend itself, instead of creating a peer review panel, to see if there could have been a more positive outcome. ... You have to bear in mind that Coroner, Michael Singleton, has in the past, raised concerns about the procedures and treatments that patients receive at BRH, so instead of writing privately, he has made a statement in open court, where he has raised his concerns, again. The hospital, for it's part, has made an open reply, I assume, sensing a slight whiff of litigation in the air, so as to allay anyone's mounting concerns over how you are treated there. (Perhaps my comments of, St Elsewhere, are being read.) In closing, let me state that this ladies already compromised immune system because of Chemotherapy, may have contributed to the speed of her illness but at the same time, it is apparent to me, from this article, that a more timely intervention procedure, in the correct setting, just may have had made a difference. We may never know, as long as the hospital staff don't conduct a proper and full investigation into the circumstances. My condolences to all concerned, goes without saying. woolywords
  • Score: 5

3:16pm Sat 5 Jul 14

shabba says...

woolywords wrote:
Fire Fly,
With the best will in the world, I cannot agree with your assumptions and having re-read the article to assure myself of the events and the timeline, I offer a differing view.
The lady is taken ill, above her existing condition and a Doctor is called to see her and in his opinion, she requires being taken to hospital immediately for a particular kind of care. The question then arises; why wasn't his wishes complied with, by the ambulance crew and who directed them to UCC?
Upon arrival, it is stated that 34 minutes elapse before the correct treatment is given and given the constraints of the 'Golden Hour', for a positive outcome to treatment, where do these 34 minutes lay?
...
When a Coroner gives a narrative verdict it is because he cannot quite put his finger on exactly what the cause of death is, apart from the underlying condition. He has to draw a conclusion from the sequence of events and it seems as though, A+B+C+D+E were such that he can only conclude that each, to a greater or lesser degree, have contributed to the outcome. If he feels that certain procedures weren't followed then he will raise concerns with those whom must shoulder the blame.
In this case, the hospital has decided to publicly defend itself, instead of creating a peer review panel, to see if there could have been a more positive outcome.
...
You have to bear in mind that Coroner, Michael Singleton, has in the past, raised concerns about the procedures and treatments that patients receive at BRH, so instead of writing privately, he has made a statement in open court, where he has raised his concerns, again. The hospital, for it's part, has made an open reply, I assume, sensing a slight whiff of litigation in the air, so as to allay anyone's mounting concerns over how you are treated there. (Perhaps my comments of, St Elsewhere, are being read.)
In closing, let me state that this ladies already compromised immune system because of Chemotherapy, may have contributed to the speed of her illness but at the same time, it is apparent to me, from this article, that a more timely intervention procedure, in the correct setting, just may have had made a difference.
We may never know, as long as the hospital staff don't conduct a proper and full investigation into the circumstances. My condolences to all concerned, goes without saying.
The "Golden Hour" applies to Trauma patients not medical so is Irrelevant at Blackburn the A&E and UCC are in the same place with the same staff this is a sad story but with Neutropenic sepsis in a Cancer patient the outcome would have been the same. The hospital is always getting bad press but I feel they do an outstanding job with the volume of patients they have coming through the doors, many of which could be treated at home by themselves or by their GP if they could get an appointment within a realistic time frame.
[quote][p][bold]woolywords[/bold] wrote: Fire Fly, With the best will in the world, I cannot agree with your assumptions and having re-read the article to assure myself of the events and the timeline, I offer a differing view. The lady is taken ill, above her existing condition and a Doctor is called to see her and in his opinion, she requires being taken to hospital immediately for a particular kind of care. The question then arises; why wasn't his wishes complied with, by the ambulance crew and who directed them to UCC? Upon arrival, it is stated that 34 minutes elapse before the correct treatment is given and given the constraints of the 'Golden Hour', for a positive outcome to treatment, where do these 34 minutes lay? ... When a Coroner gives a narrative verdict it is because he cannot quite put his finger on exactly what the cause of death is, apart from the underlying condition. He has to draw a conclusion from the sequence of events and it seems as though, A+B+C+D+E were such that he can only conclude that each, to a greater or lesser degree, have contributed to the outcome. If he feels that certain procedures weren't followed then he will raise concerns with those whom must shoulder the blame. In this case, the hospital has decided to publicly defend itself, instead of creating a peer review panel, to see if there could have been a more positive outcome. ... You have to bear in mind that Coroner, Michael Singleton, has in the past, raised concerns about the procedures and treatments that patients receive at BRH, so instead of writing privately, he has made a statement in open court, where he has raised his concerns, again. The hospital, for it's part, has made an open reply, I assume, sensing a slight whiff of litigation in the air, so as to allay anyone's mounting concerns over how you are treated there. (Perhaps my comments of, St Elsewhere, are being read.) In closing, let me state that this ladies already compromised immune system because of Chemotherapy, may have contributed to the speed of her illness but at the same time, it is apparent to me, from this article, that a more timely intervention procedure, in the correct setting, just may have had made a difference. We may never know, as long as the hospital staff don't conduct a proper and full investigation into the circumstances. My condolences to all concerned, goes without saying.[/p][/quote]The "Golden Hour" applies to Trauma patients not medical so is Irrelevant at Blackburn the A&E and UCC are in the same place with the same staff this is a sad story but with Neutropenic sepsis in a Cancer patient the outcome would have been the same. The hospital is always getting bad press but I feel they do an outstanding job with the volume of patients they have coming through the doors, many of which could be treated at home by themselves or by their GP if they could get an appointment within a realistic time frame. shabba
  • Score: 10

7:13pm Sat 5 Jul 14

shazadi says...

step down Ian Stanley you and the rest of the directors should be charged for manslater. how many more deaths will it take before you lot resign..
step down Ian Stanley you and the rest of the directors should be charged for manslater. how many more deaths will it take before you lot resign.. shazadi
  • Score: -2

7:20pm Sat 5 Jul 14

shazadi says...

Ian Stanley medical director the chiefs medical nurse and the chief executive and the rest of the directors should be charged for manslater. I an fed up listening to all the blunder week after week people needless dieing how many more deaths will it take before someone takes action. I really cant wait to see the daming report by the CQC later this months
Ian Stanley medical director the chiefs medical nurse and the chief executive and the rest of the directors should be charged for manslater. I an fed up listening to all the blunder week after week people needless dieing how many more deaths will it take before someone takes action. I really cant wait to see the daming report by the CQC later this months shazadi
  • Score: 0

7:54pm Sat 5 Jul 14

Openminded? says...

shazadi wrote:
Ian Stanley medical director the chiefs medical nurse and the chief executive and the rest of the directors should be charged for manslater. I an fed up listening to all the blunder week after week people needless dieing how many more deaths will it take before someone takes action. I really cant wait to see the daming report by the CQC later this months
Are you serious? Charge them, who will replace them? Some others, and then charge them with manslaughter when someone dies?

You listen to blunder week after week, because this newspaper, pick and prods and find reasons to publish a negative article.

What about the no doubt, countless of lives saves and improved by the Hospital, but yet all we hear is bad, bad and bad.
[quote][p][bold]shazadi[/bold] wrote: Ian Stanley medical director the chiefs medical nurse and the chief executive and the rest of the directors should be charged for manslater. I an fed up listening to all the blunder week after week people needless dieing how many more deaths will it take before someone takes action. I really cant wait to see the daming report by the CQC later this months[/p][/quote]Are you serious? Charge them, who will replace them? Some others, and then charge them with manslaughter when someone dies? You listen to blunder week after week, because this newspaper, pick and prods and find reasons to publish a negative article. What about the no doubt, countless of lives saves and improved by the Hospital, but yet all we hear is bad, bad and bad. Openminded?
  • Score: 8

9:38pm Sat 5 Jul 14

Fire Fly says...

woolywords....
as stated, the golden hour is not for medical patients. The condition this Lady was admitted with is a complication of chemo...not something above her existing condition as you say. If the Golden hour had applied...there were still 26mins to go & still well within the hour...therefore not a failure at 34mins...as per golden hour guidance.

34 mins from arrival...apparently in the wrong place to consultant review & then treatment.....given all that happens when a patient attends A&E via ambulance ...that's v fast indeed.

If you are so certain from press articles that the Coroner is correct, then at least give as much credence to ELHT as you have him. You basically have no facts either side..or medical knowledge which is important in cases such as this.

The condition this lady was admitted with...is often fatal. Triage can't change that.
woolywords.... as stated, the golden hour is not for medical patients. The condition this Lady was admitted with is a complication of chemo...not something above her existing condition as you say. If the Golden hour had applied...there were still 26mins to go & still well within the hour...therefore not a failure at 34mins...as per golden hour guidance. 34 mins from arrival...apparently in the wrong place to consultant review & then treatment.....given all that happens when a patient attends A&E via ambulance ...that's v fast indeed. If you are so certain from press articles that the Coroner is correct, then at least give as much credence to ELHT as you have him. You basically have no facts either side..or medical knowledge which is important in cases such as this. The condition this lady was admitted with...is often fatal. Triage can't change that. Fire Fly
  • Score: 7

2:37am Sun 6 Jul 14

shabba says...

Fire Fly wrote:
woolywords....
as stated, the golden hour is not for medical patients. The condition this Lady was admitted with is a complication of chemo...not something above her existing condition as you say. If the Golden hour had applied...there were still 26mins to go & still well within the hour...therefore not a failure at 34mins...as per golden hour guidance.

34 mins from arrival...apparently in the wrong place to consultant review & then treatment.....given all that happens when a patient attends A&E via ambulance ...that's v fast indeed.

If you are so certain from press articles that the Coroner is correct, then at least give as much credence to ELHT as you have him. You basically have no facts either side..or medical knowledge which is important in cases such as this.

The condition this lady was admitted with...is often fatal. Triage can't change that.
exactly fire fly sad as it is the outcome would be the same golden hour would not apply RIP and thoughts with the family x
[quote][p][bold]Fire Fly[/bold] wrote: woolywords.... as stated, the golden hour is not for medical patients. The condition this Lady was admitted with is a complication of chemo...not something above her existing condition as you say. If the Golden hour had applied...there were still 26mins to go & still well within the hour...therefore not a failure at 34mins...as per golden hour guidance. 34 mins from arrival...apparently in the wrong place to consultant review & then treatment.....given all that happens when a patient attends A&E via ambulance ...that's v fast indeed. If you are so certain from press articles that the Coroner is correct, then at least give as much credence to ELHT as you have him. You basically have no facts either side..or medical knowledge which is important in cases such as this. The condition this lady was admitted with...is often fatal. Triage can't change that.[/p][/quote]exactly fire fly sad as it is the outcome would be the same golden hour would not apply RIP and thoughts with the family x shabba
  • Score: 4

10:44pm Sun 6 Jul 14

peely says...

The LT need to find some other new s for a change instead of constantly trying to undermine all the good work that goes on at Royal Blackburn .Why don't they post some opinions from patients who are extremely grateful for the successful treatment they,ve had . It,s just cheap headlines and repeat cheap stories ! Shameful !
The LT need to find some other new s for a change instead of constantly trying to undermine all the good work that goes on at Royal Blackburn .Why don't they post some opinions from patients who are extremely grateful for the successful treatment they,ve had . It,s just cheap headlines and repeat cheap stories ! Shameful ! peely
  • Score: 4
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