Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0219, written 28 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Aug 2013 |
|---|---|
| Reference | 2013-0219 |
| Deceased | Dorothy Townley |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Royal College of General Practitioners
2. Royal College of Nursing
CORONER
| am Joanne Kearsley, HM Area Coroner for the area Manchester South.
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
{| _
3 | INVESTIGATION and INQUEST
On the 24th October 2012 | commenced an investigation into the death of Dorothy
Townley, 94 years of age. The investigation concluded at the end of the Inquest on the
20th August 2013. The conclusion of the Inquest was that the deceased died as a result
of an accidental death.
4 | CIRCUMSTANCES OF THE DEATH
On the 28" September 2012 at her home address the deceased had spilt a cup of tea,
sustaining burns which developed and became infected. There were missed
opportunities to consider earlier hospital intervention. On the 11" October 2012 she was
admitted to hospital but despite active treatment her condition deteriorated and she died
on the 20" October 2012.
Having spilt her tea on the 28" September she was washed and changed by her carer
who was present. The next day the area on her chest looked a little red, however by the
30" two blisters had developed and the carer called the District Nurses. District Nurses
attended that day and applied dressings to the blistered area which by this stage had
burst. She was then seen the following day when a prescription for further dressings
was written and she was listed for visits every 2 days. On the 3" October the dressings
had not been delivered and by this stage her chest and left breast area were exuding
from blistered areas and looked sore. She was changed to daily visits. On the 4
October more skin loss was noted and a GP visit was requested as it was felt that the
site was infected.
Her GP visited the following day on the 5” October. This was not a joint visit. In
evidence the GP indicated he had received a request to visit Mrs Townley. He did not
examine her chest as this would have meant taking the dressing off her and it was his
belief that there were no replacement dressings available in the property. He looked
and could see the superficial wounds on the outer edges which “looked to be healing
ok”. He did not prescribe antibiotics as he felt they were not required, he did prescribe
Flamazine cream. He indicated in evidence that to a large extent, in relation to wound
care, GPs are led by the nurses.
The District Nurses continue to visit. On the 6" October they are concerned about her
condition. Her wound and condition continue to deteriorate. On the 10" October the
District Nurses request a further GP visit. The GP re-attends; again this is not a joint
visit. Her dressing is not removed and antibiotics are not prescribed. He notes the
deterioration in her condition, that she had visibly deteriorated, was very dehydrated and
not keeping much down. However he stated that he did not think this was related to her
wound. In evidence the GP indicated that he planned to take a blood test from Mrs
Townley, he could not do this at the time of his visit on the 10" as he did not have the
equipment to do so although he felt that a blood test was required urgently. There was
then some confusion in the evidence as to what happened but it appears that on return
to the GP practice on the 10" a request was made to the District Nurses to take a blood
test from Mrs Townley. This was not marked as urgent. On the 11" October the GP re-
attended Mrs Townley's address on the chance he would see her and take the blood
test (it was not known by him whether in fact the District Nurses would have already
done this.) As this was an unscheduled visit Mrs Townley was on her own in the
property and was too poorly to be able to open the door. He left the property and as he
was aware that the District Nurses would be calling later that day did not do anything
further. When the District Nurses attended on the 11" they called the Out of Hours
Doctor who immediately admitted Mrs Townley to hospital. She was transferred
immediately to the Specialist Burns Unit at Wythenshawe Hospital, who immediately
raised a safeguarding alert with regards to her condition. It was recorded that she had 5-
6% second degree burns covering most of her upper chest. These were infected; she
was very dehydrated and had atrial fibrillation. The Consultant who gave evidence at
the Inquest confirmed that in a 94 year old lady with frail skin this was a significant burn
which had developed; he would have expected her to be referred to them much sooner.
Despite all active treatment Mrs Townley died on the 20" October.
During the Inquest | heard evidence from the Clinical Lead for District Nursing who
indicated that at the time of this incident there was nothing in place within the District
Nursing Service to help them deal specifically with burns. The Wound Assessment
Chart used was not suitable for recording burns. There was no consideration of referral
or input being requested from the OUTREACH service at the Specialist Burns Unit (a
service in place at the time where specialist trained nurses can offer advice to
community nurses/doctors on the management of burns).
5 | CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
1. There was a lack of direct communication between the District Nurses and the
GP as to exactly what the deceased’s condition was and what was required on
visits. There was no consideration given to carrying out joint visits, no
communication as to how Mrs Townley’s wound could be examined if there
were no dressings available.
2. There was a lack of knowledge within the District Nursing Team around the
treatment of burns.
3. The wound assessment chart did not assist as it was not as detailed as it should
be for burns in order to help chart their progress or deterioration.
4. There was a lack of training for District Nurses on the treatment of burns.
5. There was a lack of understanding between the GP and District Nurses as to
how to request urgent blood tests. It was assumed by the GP that his request
for a blood test would be treated as urgent and done that day (on 10"): the
District Nurses indicated it would only be carried out as ‘urgent’ if requested.
In my opinion action should be taken to prevent future deaths and | believe your
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 24/10/13. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: [NEEM (Son of the deceased), Bredbury Medical Centre and Stockport
| am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
6 | ACTION SHOULD BE TAKEN
organisation has the power to take such action.
7 | YOUR RESPONSE
8 | COPIES and PUBLICATION
District Nursing Team.
9
Date: S. Bi
Signed by: _|
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
RC Royal College of Ga P General Practitioners nt Honorary Secretary Ms Joanne Kearsley rer | HM Area Coroner - Manchester South : xy HEH Coroner’s Court \ 95 RON duis | Mount Tabor \ Mottram Street Stockport SK1 3PA irae 29 October 2013 Dear Ms Kearsley Rule 43 — Coroners Rules report — Dorothy Townley (deceased) Thank you for your letter addressed to the College's Chief Executive which has been passed to me for response as Honorary Secretary. On behalf of the College, | give below our comments on the inquest report. The role of the College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 44,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants. As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College. However, not all GPs are members of the College, and older GPs may never have joined. The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified.. Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we do in the context of training and advice to our Members. As a general observation, it would seem that the GP looking after Mrs Townley was obviously concerned about his patient and was conscientious about carrying out home visits, including making an unscheduled visit to Mrs Townley to see her and to check that the specified blood test had been carried out. However, | would agree with the concerns listed about the management of the actual burn injury and the wound assessment chart by the District Nursing staff. Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 From the perspective of general practice, | would comment that the College can influence the training of general practitioners through the guidelines for best practice it sets out in the College’s GP Curriculum. (The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College’s Membership Examination (MRCGP) and is relevant to GPs throughout their career, including preparation for revalidation) http:/Avww.rcgp.org.uk/gp-training-and-exams/gp-curriculum-overview.aspx In this case, there are issues about communications between professionals and the following sections of the GP Curriculum are of particular relevance in the case of the care of Mrs Townley: “Being a GP “As a GP you should: 1.4.2 Understand the processes of referral into secondary care and other care pathways 1.4.3 Manage the interface between primary and secondary care, including unscheduled care and communication with other professionals” “Patient Safety and Quality of Care “As a GP you should 4.2 Reflect on the risks to patient safety in a care pathway in which a variety of healthcare professionals are involved, looking at interface issues and be able to comment on the ways in which, as a GP, you can work to minimise these” “The GP in the Wider Professional Environment “As a GP you should 1.2.3 Work effectively with the full range of primary care services, and across the primary-secondary care interface for the benefit of patients.” Additionally, the case highlights the need for general practitioners to systematically audit their work and to carry out significant event analysis where appropriate. The SEA is a standard method employed in GP appraisal process. The document Good Medical Practice for GPs (RCGP, 2008) sets out the principles underpinning the revalidation and appraisal process. http://www.rcgp.org.uk/revalidation-and-cpd/~/media/Files/Revalidation-and- CPD/CPD%20Credits%20and%20Appraisal/GoodMedicalPracticeforGPsJuly2008ashx.ashx | hope you find these comments helpful. Yours sincerely Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106
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