Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0244, written 20 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 | 20 Aug 2013 |
|---|---|
| Reference | 2013-0244 |
| Deceased | Derek Brierley |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| 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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Pennine Acute Trust
2. The Chief Medical Officer England & Wales
3. The Chief Coroner
4. Family of the deceased
1
CORONER
I am the Senior Coroner, for the coroner area of Manchester North
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
3
INVESTIGATION and INQUEST
On 17/08/2012 I commenced an investigation into the death of Derek BRIERLEY, then aged 86
Years. The investigation was concluded at the end of the inquest on 17/08/2013. The conclusion of
the inquest was “Recognised but rare complication of necessary surgical intervention.”, the medical
cause of death being 1a Bronchopneumonia 1b post peritonitis after insertion of superapubic
catheter for benign prostatic hyperplasia 1c blocked urethral catheter for benign prostatic hyperplasia
4
CIRCUMSTANCES OF DEATH
Mr Brierly’s catheter was not working on the morning of the 21st July 2012. A district nurse was
unable to recatheterise him at home and so he was conveyed by ambulance to the Royal Oldham
Hospital where three further attempts by a nurse, junior doctor and consultant were also
unsuccessful by which time Mr Brierly had a palpably distended bladder. The Consultant’s attempt at
a suprapubic insertion via the abdomen was abandoned following which Mr Brierly became acutely
unwell with features of peritonitis
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) Although the consultant performing the suprapubic procedure had done so successfully on nine
previous occasions the last such occasion was twelve months earlier. The family overheard
instructions for the procedure being read out to the consultant whilst it was being carried out. More
likely than not the site of the insertion was too high.
2) There are no Trust Guidelines as to the standard of competence or training of those carrying out
the procedure
3)Difficulties were encountered in locating a suprapubic catheter prior to the procedure
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you (AND/OR 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 the
24th of 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner.
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 from. 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
20 August 2013. Signed Simon Nelson
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.
If calling please ask for: Our ref: ARS/SB 22 November 2013 Mr S Nelson H M Coroner The Phoenix Centre Church Street Heywood OL10 1LR Dear Mr Nelson as wr The Pennine Acute Hospitals INHS| NHS Trust za wiae Trust Headquarters North Manchester General Hospital Delaunays Road Crumpsall Manchester M8 5RB Telephone: 0161 604 5454 Facsimile: 0164 604 5472 Further to your Regulation 28 dated 30" September 2013 for events relating to the death of Mr Derek Brierley, | can report that the following actions have been taken to prevent future deaths: 1) The pathway for managing urinary retention has been re-drafted & supra-pubic aspiration is the first line intervention for those unable to insert supra-pubic catheters, followed by transfer to North Manchester Urology department or A&E. (Summary Pathway enclosed) 2 ~~ opportunity to comment on it). 3 ~ The pathway has been shared with A&E staff so that they are aware of it (& they had The urology team have initiated a training program for those who may need to insert such catheters outside of the urology division. Individuals will need to be signed off for this, (a process we already use for chest drains). 4) Those deemed competent include CT1 trainees & above for urology who have undergone the training, middle grade & above surgical trainees, other trainees at ST3 level & above who have undergone the training. 5) Bladder scanning should be done before such procedures are attempted. (This was actually done in this particular case). 6)..Such cases should be discussed with the urology team. (TI his was done in this particular case). PLEASE NOTE THE TRUST HAS A SMOKE FREE ENVIRONMENT POLICY FOR STAFF, PATIENTS AND VISITORS. THIS INCLUDES BUILDINGS, GROUNDS AND CAR PARKS. 7) The governance lead for urology will continue to monitor catheter related incidents to ensure standards & processes are followed, but also ensure that adverse incidents are reported as clinical incidents. 8) Procedure trays are clearly labelled, regularly checked & appropriately stored. Difficulty finding the kit in this case was due to individual lack of familiarity as it is nota procedure frequently performed in a very busy A&E. | believe that the above measures should ensure that this rare, but recognised complication of supra-pubic catheter insertion should not lead to a preventable death again. Yours sincerely Deputy Medical Director Encl: Summary Pathway PLEASE NOTE THE TRUST HAS A SMOKE FREE ENVIRONMENT POLICY FOR STAFF, PATIENTS AND VISITORS. THIS INCLUDES BUILDINGS, GROUNDS AND CAR PARKS.
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