Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0237, written 24 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 | 24 Sep 2013 |
|---|---|
| Reference | 2013-0237 |
| Deceased | Jude Augustus Gordon |
| Coroner | Donald Coutts-Wood |
| Coroner area | South Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for the Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 CORONER Donald Coutts-Wood assistant coroner for the coroner area of South Yorkshire (West). 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. Schedule 5 to those Regulations provides: (1) Where— (a) a senior coroner has been conducting an investigation under this Part into a person’s death, (b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. (2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner. 3 INVESTIGATION and INQUEST On the 1st December 2011 I commenced an investigation into the death of Jude Augustus Gordon, who was born on the 26th May 1958. The investigation concluded at the end of the inquest on the 29th August 2013. The conclusion of the inquest was that Mr Gordon died from cardio respiratory failure, due to ileus of the small intestine, due to restoration of bowel continuity due to Crohn’s Disease. Ankylosing Spondylitis was a significant contributory factor. Mr Gordon was in hospital and following a sudden deterioration in his condition, such deterioration being recognised, the level of treatment for Mr Gordon was not increased. 1 4 CIRCUMSTANCES OF THE DEATH Mr Gordon underwent successful surgery and anaesthesia on the 23rd November 2011 and initially his recovery was uncomplicated. However, at about 0730 hours on the 27th November his condition deteriorated and there were objective signs of respiratory failure. It was recognised by staff that there was a problem, but the need to attend to that problem was not acted upon. He was not referred to more specialist care such as critical care. He went for a CT scan later that day and on returning to the ward suffered a cardiac arrest and died very shortly afterwards. One of the objective signs of his deterioration that morning was the Early Warning Score. In the Sheffield hospitals this is referred to as the SHEWS. It is not clear whether any referral to more specialist care would have led to a different outcome for Mr Gordon. (A copy of the SHEWS Guide is enclosed). 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) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system. (2) Evidence was given at the inquest, by a consultant, that if he had been called to see Mr Gordon at the time his condition deteriorated, as was indicated by the Early Warning Score system should have happened, then he would have referred to critical care. He was not contacted. I was informed at the inquest that a Trust in Birmingham has a computerised system, that leads to an automatic alert to the relevant senior doctor on each occasion that a Early Warning Score exceeds the relevant level, for contact to be required. Such a system would on the 27th November 2011, to the consultant attending on Mr Gordon. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. Is there an intention for a National scoring system to be introduced, and indeed is consideration being given to the introduction of computerised systems that lead to automatic referral to the relevant senior doctor? 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th November 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 1. Mr Gordon’s family 2. The Chief Executive, Sheffield NHS Foundation Trust 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 24th September 2013 3
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.
é From the Rt Hon Jeremy Hunt MP LAER? Secretary of State for Health Department of Health . Richmond House 79 Whitehall POCI_ 810786 London SILA 2NS Mr D Coutts-Wood Tel: 020 7210 3000 Assistant Coroner Mb-sofs@dh. gsi.gov.uk The Medico-Legal Centre Watery Street Sheffield Dew vv, Comtts -Usosd ; Thank you for your letter following the inquest into the sad death of Jude Augustus Gordon. In your report you state that Mr Gordon died from cardio respiratory failure, with Ankylosing Spondylitis being a significant contributory factor. Following a sudden deterioration in his condition, although the deterioration was recognised by staff, the need to attend to that problem was not acted upon and subsequently the level of treatment was not increased. You raise two areas of concern relating to early warning scoring systems and in conclusion recommend that : a) a national early warning scoring system be introduced; and, b) consideration be given to the introduction of computerised systems that lead to automatic referral to the relevant senior doctor. In relation to your first area of concern, work is already being taken forward. In July 2012 a report entitled National early warning score (NEWS); standardising the assessment of acute-illness severity in the NHS, was published by the Royal College of Physicians. The multi-disciplinary working party on the report was chaired by Professo Professor of Medicine at University College, London. This report advocates the use of a NEWS to assist in standardising assessment of the severity of acute illness. To support this clinical observation, charts and e- learning materials were produced by a collaborative project funded by the Royal College of Physicians, the Royal College of Nursing, the National Outreach Forum and NHS Training for Innovation. There is however as yet no national requirement for this approach to be followed, although the report strongly encouraged Trusts to do so voluntarily to ensure a consistent and high-standard approach. Furthermore, the Patient Safety Domain of NHS England is developing work to identify and implement actions to prevent deterioration of patients whose conditions are amenable to treatment. One of the outputs of this programme is likely to be guidance to staff about best practice, supported by material to develop and improve front line clinician skills in this area. Your second recommendation relates to computerised systems linked to the EWS score, You ask if consideration is being given to the introduction of computerised systems that lead to automatic referral to the relevant senior doctor. The system operational in a Birmingham Trust depends on patient observations being recorded in the Patient Information Communication System (PICS), the Trust’s rules-based clinical information, drug prescribing and administration system. As observations are entered an early warning score is generated. Depending on the score generated and the settings programmed, an automatic message can be sent to designated nursing and medical staff. Currently, NHS England has no plans to require computerised EWS systems more widely across more than 150 NHS acute trusts and foundation trusts. This is because development of an electronic system such as this relies on the individual Trust’s IT infrastructure, which is not standard across the NHS. For each Trust to develop an electronic EWS system it would need to have the required IT capability. It is not something that is simple to implement and deploy across the wider NHS. This may explain why it appears to be operational at present only in the Birmingham Trust. Secondly, both electronic systems and paper based systems are reliant on local clinical observations and require observations to be recorded and entered properly before an alert could be generated to a senior clinician. The early warning system should be considered not as a substitute for, but an aid to, clinical decision making, based on the clinical judgement of the responsible clinician. All forms of early warning system depend on accuracy in completion, calculation of the relevant score and trigger settings, and (subsequently) staff escalating to the appropriate senior clinician; this latter point is well understood in the Sheffield Hospitals Early Warning Score documentation. Department | of Health Therefore, regardless of the system in use, whether local or national, I believe effectiveness will always be predominantly governed by locally tailored staff training and updating. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Gordon’s death to my attention. Yn wy a JEREMY HUNT
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.