Parsons, Ann

Contributing factors

• Delay of 16 days in scheduling surgery due to consultant taking planned leave without appropriate handover
• Absence of formal preoperative neurological assessment and speech pathology baseline despite documented speech difficulties
• Post-operative ischaemic stroke (posterior cerebral artery territory infarction) not adequately communicated to ward staff
• Failure to ensure CT scan findings were handed over to receiving ward team
• Inappropriate discharge from ICU to ward within 22 hours of major neurosurgery complicated by stroke
• Absence of clear documentation and direction regarding frequency of neurological observations on ward
• Inconsistent observation frequency (two hourly vs four hourly) with only four observations recorded over 14-hour period
• Glasgow Coma Scale used as sole assessment tool despite significant expressive dysphasia making verbal component unreliable
• Consultant surgeon (Dr T.) not informed of critical CT findings or clinical deterioration
• Excessive intraoperative fluid administration (3 litres) contributing to dilution and subsequent hyponatraemia
• Hyponatraemia (sodium 120 mmol/L) developed with no early detection or intervention
• Poor communication and documentation of medical decision-making throughout admission
• Family concerns raised on ward not appropriately escalated

Coroner's recommendations

1. Conduct in-service training on importance of documentation and reinforce policy requirements for all medical staff on neurosurgical ward, including consultants
2. Regular follow-up audit of medical entries to ensure documentation policy compliance
3. Amend clinical/case pathway for craniotomy patients with brain tumour to require comprehensive speech pathologist or neurology team review when preoperative communication deficits present, ensuring timely baseline assessment
4. Amend clinical/case pathway to require operating surgeon(s) to complete preoperative comprehensive detailed high cognitive function neurological assessment, clearly documented on record
5. Amend clinical/case pathway to consider preoperative CT/MRI scan within 3-5 days prior to surgery, with surgeon required to document reason if decision made not to arrange such imaging
6. Present Mrs Parsons case to junior medical and nursing neurological training to highlight importance of identifying changes in speech, restlessness and changes in patient's ability to follow commands
7. Conduct audit to check whether consultant to consultant discharge of neurological patients is occurring in intensive care unit in accordance with root cause analysis recommendations