Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0223, written 4 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Sep 2013 |
|---|---|
| Reference | 2013-0223 |
| Deceased | Karen Sutton |
| Coroner | Lydia Brown |
| Coroner area | Leicester City & South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TOPREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr John Adler Chief Executive, University Hospitals Leicester NHS Trust 1 CORONER I am Lydia Brown assistant coroner, for the coroner area of Leicester City and South Leicestershire 2 CORONER’S LEGAL POWERS I 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 18th October 2012 an investigation commenced into the death of Karen Lesley SUTTON date of birth 10 November 1959. The investigation concluded at the end of the inquest on 2nd September 2013. The conclusion of the inquest was Natural Causes. The cause of death was 1a. Sepsis 1b. Streptococcus pneumoniae infection 1c. Common variable immunodeficiency and low grade non-Hodgkin Lymphoma and Splenectomy 2. Hepatic cirrhosis 4 CIRCUMSTANCES OF THE DEATH Mrs Sutton had been diagnosed with primary antibody deficiency disorder in September 2001 and from this time was under the care of the Immunology teamand her care was at Leicester Royal Infirmary. As part of her ongoing treatment she led by underwent splenectomy during 2005, and thereafter required lifelong anti-biotic therapy most latterly in the form of daily azithromycin. She required admissions during August and September 2012 for symptoms of infection, and was treated by the medical teams at Glenfield Hospital. Her admission medications including Antibiotic prophylactic cover were discontinued, and not restarted on discharge. Mrs Sutton was readmitted on 11th October 2012 as an emergency and was found to be suffering from a severe sepsis, and despite timely interventions, went into cardiac arrest and died that evening. 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) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge. (2) Mrs Sutton was discharged home without prophylactic antibiotic medication (3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that (4) departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide. was able to see her after the day of discharge, 4th October 2012. was unaware of any Trust policy to share admissions between 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 October 2013. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons . I 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. 9 Date 4 September 2013 Mrs L Brown H M Assistant Coroner Leicester City and South Leicestershire
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.
Leicester Royal Infirmary Leicester LE1 5WW Tel: 0300 303 1573 Fax: 0116 258 7565 Minicom: 0116 287 9852 Tel: Your Ref: CEM/AMO/02281-2012 23 October 2013 HM Coroner The Town Hall Town Hall Square LEICESTER LE1 9BG Dear Mrs Mason Re: Karen Lesley Sutton Thank you for the letter of 4th September 2013 that your Assistant Coroner wrote to me in accordance with Regulation 28 of the Coroners Rules following the conclusion of the inquest that was held into the death of Karen Sutton. I note the concerns that are raised in that letter namely:- 1. That the immunology team were not notified of Mrs Sutton’s admission to hospital. 2. That Mrs Sutton was discharged home without prophylactic antibiotic medication. 3. That Mrs Sutton was left to arrange her next outpatient appointment with which occurred on the 4th October 2012. 4. That admissions were not shared between departments. All four of your concerns raise the issue of communication. When Mrs Sutton was admitted the following process was in place and should have been followed. The admitting Consultant should ensure that s/he is aware of the clinical needs of the patient and further ensure that s/he consults appropriately with other clinical specialties where the patient has complex needs which fall outside of that consultant’s competence. As a result of your concerns we have strengthened our current process by undertaking the following actions: a) The Medical Director has written to all Consultants in the Trust to remind them of their duty to contact specialist teams in the event of a patient with complex needs being admitted to hospital and placed under their care if a patient’s care needs fall outside the Consultant’s competence. b) We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust. In the run-up to the 1 integration of this software we will ask every Consultant in the Trust to identify the patients in their service whom they feel fit into this category in order to ensure that the process is successful. In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre- admission medication. As to your third concern the circumstances surrounding the outpatient appointment with are unusual. I am informed that the on the 25th May 2012 an outpatient was booked for 4th October 2012 in accordance with normal appointment with procedures. As you are aware Mrs Sutton was subsequently admitted under the care of the respiratory team. It would seem that whilst there was a plan made on the 2nd October 2012 to cancel this appointment, as Mrs Sutton was then an inpatient, our Patient Administration system (HISS) indicates that this cancellation had not been put into effect by the 3rd October when Mrs Sutton was discharged. A plan was therefore made, prior to discharge, that Mrs Sutton should attend her pre-arranged appointment on 4th October 2012 with . This plan was described in the discharge letter which would have been available to in hard copy form from the patient as well as being available electronically on our ICE System. I am assured that the Immunology Team have access and can use the ICE system to obtain patient information on previous admissions. I am assured by our Medical Director that it can be appropriate for patients to arrange their own outpatient appointments though this will depend on the clinical circumstances that prevail at the time. This does not however remove the need for appropriate communication between different specialisms. As indicated above we have taken action to strengthen this aspect of care and will be taking the further action described. I hope that this is helpful and addresses the issue identified in your Regulation 28 Report. I would be very happy to provide any further information or to meet with you to discuss this matter further. Yours sincerely John Adler Chief Executive (signed electonically) Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www.uhl-tr.nhs.uk Acting Chairman Richard Kilner Chief Executive Mr John Adler University Hospitals of Leicester NHS Trust includes 2
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