Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0263, written 17 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Oct 2013 |
|---|---|
| Reference | 2013-0263 |
| Deceased | Rosa Anderson |
| Coroner | Andre Rebello |
| Coroner area | Liverpool |
| Category | Hospital Death (Clinical Procedures and medical management) 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. The Chief Executive, Aintree Hospitals NHS Trust, Longmoor Lane, Liverpool L9 7AL 1 | CORONER lam André Rebello, Senior Coroner, for the area of Liverpool 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 | NVESTIGATION and INQUEST On 16th May 2013 | commenced an investigation into the death of Rosa ANDERSON , Aged 79. The investigation concluded at the end of the inquest on 17th October 2013. The conclusion of the inquest was la Hypoxic Brain Injury Ib Cardiac Arrest Ic Oesophageal Perforation Secondary to Laparoscopic Repair of Diaphragmatic Hernia Accidental Death 4 | CIRCUMSTANCES OF THE DEATH On 29th April 2013, Rosa Anderson underwent a laparoscopic repair of a diaphragmatic hernia at the University Hospital Aintree. During the procedure, damage was inadvertantly caused to the oesophagus within the thorax. There was no way this could have been appreciated at the time. The following day, Mrs Anderson was discharged home. The same evening she was admitted to the emergency department with abdominal pain and burning in the epigastric region. From the signs and symptoms, the breach of the oesophageal wall was not appreciated. She was referred to the surgical team and a CT Scan was arranged for the next day. With hindsight, the fact that the leaking oesophagus was not detected earlier lessened the chances of a successful resolution. : The leaking oesophagus caused mediastenitis, which compromised Mrs Anderson's breathing. This led to a cardiac arrest and hypoxic brain injury on 7th May 2013. 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. — During the course of the Inquest it was evident that Mrs Anderson was not given a discharge summary when discharged on 30°" April 2013. Further, she was given no written information about her recent Japaroscopic operation, contact telephone numbers for advice, nor were matters highlighted that required urgent medical assistance. ACTION SHOULD BE TAKEN . In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th December 2013. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Family of Mrs Anderson The Coroners Society | 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. showte. André Rebello Senior Coroner for the City of Liverpool 17" October 2013
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.
Aintree University Hospital INHS| NHS Foundation Trust Our Ref: CB/MC Executive Office 2" Floor Aintree Lodge Mr A Rebello OBE _. Aintree University Hospital H M Coroner for Liverpool RECEIVED Lower Lane St George's Hall Liverpool L9 7AL St George's Place 12 DEC 2073 Liverpool H. M. COROKE L1 1JJ 10 December 2013 Dear Sir Re: Patient RA - Ref DR 01152/2013 | write in response to your Regulation 28 Report of 18 October 2013 regarding the failure to provide written discharge information to the patient following a laparoscopic surgical procedure, including contact details for advice and action to be taken in the event of urgent medical assistance being required. | can confirm that there is now a discharge advice sheet in place, appropriate for these laparoscopic procedures and this is provided to all relevant patients prior to discharge. This discharge advice is generic for patients undergoing short stay surgery. There is also a separate patient information leaflet for patients having hiatus hernia surgery and this is given to patients pre- operatively. This also includes discharge advice for that specific group of patients. Action is also being taken to ensure that appropriate written advice is provided to all inpatients of the Trust (both Surgical and Medical) prior to discharge. A number of generic leaflets have been produced intending to cover all patients on discharge where a procedure specific information leaflet is not available. This will be implemented by 1 January 2014. In addition, a number of specialties are looking at developing their own individualised discharge information sheets and action is being taken to ensure that in such cases this is fully implemented by 1 March 2014. In the meantime, in such cases, the appropriate generic information leaflet will be provided to the patient. Yours sincerely Catherine Beardshaw Chief Executive Page 1 of 1 Advice After Discharge (Day Surgery or Short-Stay Surgery) CG APPROVED Aintree University Hospital NHS) NHS Foundation Trust Where quality matters Division of Surgery and Anaesthetics Lower Lane Liverpool L9 7AL Tel:0151-525-5980 Meeting your surgeon and anaesthetist before surgery You will have the opportunity to meet both the Surgeon and Anaesthetist prior to going into theatre e Please feel free to ask any questions you may have regarding surgery or after-surgery care. How will I feel after the operation? e¢ When your operation is over, you will be moved to the “Recovery Room” near to the operating theatre. Here you will be cared for by a specially trained health professional, until you are awake and you condition is stable. e If you have had a general anaesthetic, at first you will feel drowsy. You may feel sick and sore around the site of your operation. Your throat may feel dry, like a mild sore throat. e When you are fully recovered from the anaesthetic, the recovery/ward nurse will offer you something to drink or eat such as tea/coffee, toast or a biscuit. What operation did | have & who is my surgeon? You had Your Surgeon Secretary’s No. Leaflet Name: Discharge Information Leaflet Leaflet Lead Name: Date Leaflet Developed: October 2013 Discharge arrangements You must - Arrange for a responsible adult to accompany you home, and stay with you for 24 hours following your operation. You must let us know if you’re unable to arrange this. e Please bring enough money to cover prescriptions charges, if you have to pay for them. If you have a medicines exemption card, please bring this with you. Make sure you have a supply of your regular medication and simple painkillers e.g. paracetamol, at home for when you are discharged. Inform the nurse on admission if you require a sick leave certificate. Discharge Please note: e The average day surgery stay is half a day, while short stay surgery is usually overnight or for 2-3 nights. Discharge times may vary according to the nature of your operation and sometimes there are unforeseen delays. + Please ask your escort to contact for pick up from discharge lounge. + Wealso need a contact number for your escort home e You must not use public transport or drive yourself home. Date Leaflet Approved: 26/11/2013 Page 1 of 3 Issue Date: 06/12/2013 Ref: 1593 Review Date: 21/10/2016 Version No: 1 Post-Discharge Advice 1. If you have wounds that require removal of sutures or clips etc, arrangements will be made for these to be removed in the community by the discharge team. Please confirm the arrangements with the nurse discharging you. If you do not have stitches or clips in your wounds, the community nurse does not need to look at them. Your wounds are usually covered with waterproof dressings and you will be able to take a shower the day after sugary — dab the dressing dry quickly to avoid coming off. After about 5 days you can remove the dressing yourself. Please do not take a bath until your wound is fully healed. If you are being discharged with drains, feeding tube (gastrostomy or jejunostomy) or stoma (needing bags etc.), please ask for adequate dressing supplies (or bags) for use at home until you can get more supplies from the community nurse. Please check these arrangements with the discharging nurse. If you have any doubts about your wounds (or drains/tubes/stoma etc), please discuss with the discharging nurse or team of doctors caring for you before leaving the discharge lounge or ward. Dietary Advice Leatlet Name: Disc! jon Leaflet Standard Dietary Advice ~ Light diet for the first 24 hours, normally returning to your usual diet thereafter. It is not unusual to need to avoid some foods over the next few days - adjust your diet as necessary. ¢ Special Dietary Advice — If you have had a surgical procedure that needs specific dietary advice, then the appropriate dietary advice leaflet will be given for you to follow. If this box is ticked, please ask the discharge nurse for the advice leaflet before going home. Problems after Discharge? Please see the following advice if you have any problems at home after being discharged from hospital after surgery. (This applies to the period shortly after discharge — up to 2 weeks) A. Contacting during working hours (9am - 5pm in the working week) Please contact the secretary and leave a message for the surgical team. You will be contacted with appropriate advice or management plan. If you think that your condition is serious then it is best to come straight to Aintree Accident & Emergency department’, which can manage serious problems in the best possible manner. B. Out of hours (after 50m during working week/weekend/bank holiday) Please seek advice from your GP for minor complications. If you are not sure or if you think it is a serious problem, please come to Aintree Accident & Emergency department’ for a review and further management. Leaflet Lead Name; Date Leaflet Developed: October 2013 Date Leaflet Approved: 26/11/2013 Issue Date: 06/12/2013 Review Date: 21/10/2016 Page 2 of 3 Ref: 1593 Version No: 1 *When you come to the hospital please bring this and any other relevant discharge documents that you may have been given at the time of discharge to help the A&E doctors to decide your management easily. University Hospital Aintree has a major Accident & Emergency Department and receives many Emergency Admissions requiring priority over available beds, which may on occasion mean that planned admissions have to be cancelled at extremely short notice “> f@ lk If you require a special edition of this leaflet This leaflet is available in large print, Braille, on audio tape or disk and in other languages on request. Please contact the Equality and Diversity Department on: 0151 529 4969 Aintree University Hospital NHS Foundation Trust is not responsible for the content of any material referenced in this leaflet that has not been produced and approved by the Trust. Leaflet Name: Discharge Information Leaflet Date Leaflet Approved: 26/11/2013 Leaflet Lead — Issue Date: 06/12/2013 Date Leaflet Developed: October 2013 Review Date: 21/10/2016 ! Page 3 of 3 Ref: 1593 Version No: 1 Advice After Discharge (Complex Benign Surgery) CG APPROVED y& Aintree University Hospital NHS | NHS Foundation Trust Where quality matters Division of Surgery and Anaesthetics Lower Lane Liverpool L9 7AL Tel:0151-525-5980 Meeting your surgeon and anaesthetist before surgery You will have the opportunity to meet both the Surgeon and Anaesthetist prior to going into theatre Please feel free to ask any questions you may have regarding surgery or after-surgery care. How will | feel after the operation? What operation did | have & who is When your operation is over, you will be moved to the “Recovery Room” near to the operating theatre. Here you will be cared for by a specially trained health professional, until you are awake and your condition is stable. If you have had a general anaesthetic, at first you will feel drowsy. You may feel sick and sore around the site of your operation. Your throat may feel dry, like a mild sore throat. After the operation you will be taken back to the ward or if you need extra care you will be taken to the Critical Care Unit as appropriate. my surgeon? You had Your Surgeon Clinical Nurse Specialist Secretary’s No. Discharge arrangements You must - Please bring enough money to cover prescriptions charges, if you have to pay for them. If you have a medicines exemption card, please bring this with you. Make sure you have a supply of your regular medication and simple painkillers e.g. paracetamol, at home for when you are discharged. Inform the nurse on admission if you require a sick leave certificate. Discharge Please note: The average stay in hospital after major surgery will be discussed with you by the operating surgeon and your specialist nurse. Your stay may be longer if you develop any complications. Please ask your escort to contact for pick up from discharge lounge. We also need a contact number for your escort home eaflet Lead Name: Date Leaflet Developed: Leaflet Name: Discharge Information Leaflet Le clober Date Leaflet Approved: 26/11/2013 Issue Date: 06/12/2013 Review Date: 21/10/2016 Page 1 of 3 Ref: 1596 Version No: 1 You must not use public transport or drive yourself home. Post-Discharge Advice 1. If you have wounds that require removal of sutures or clips eic, arrangements will be made for these to be removed in the community by the discharge team. Please confirm the arrangements with the nurse discharging you. If you do not have stitches or clips in your wounds, the community nurse does not need to look at them. Your wounds are usually covered with waterproof dressings and you will be able to take a shower the day after sugary — dab the dressing dry quickly to avoid coming off. After about 5 days you can remove the dressing yourself. Please do not take a bath until your wound is fully healed. . If you are being discharged with drains, feeding tube (gastrostomy or jejunostomy) or stoma (needing bags etc.), please ask for adequate dressing supplies (or bags) for use at home until you can get more supplies from the community nurse. Please check these arrangements with the discharging nurse. . If you have any doubts about your wounds (or drains/tubes/stoma etc), please discuss with the discharging nurse or team of doctors caring for you before leaving the discharge lounge or ward. Dietary Advice Leatlet Name: Discharge Information Leaflet Leaflet Lead Name: Date Leaflet Developed: October 2013 Standard Dietary Advice — Light diet for the first 24 hours, normally returning to your usual diet thereafter. It is not unusual to need to avoid some foods over the next few days - adjust your diet as necessary. e Special Dietary Advice — If you have had a surgical procedure that needs specific dietary advice, then the appropriate dietary advice leaflet will be given for you to follow. If this box is ticked, please ask the discharge nurse for the advice leaflet before going home. Problems after Discharge? Please see the following advice if you have any problems at home after being discharged from hospital after surgery. (This applies to the period shortly after discharge — up to 2 weeks) A. Contacting during working hours (9am - 5pm in the working week) Please contact the secretary and leave a message for the surgical team. You will be contacted with appropriate advice or management plan. if you think that your condition is serious then It is best to come straight to Aintree Accident & Emergency department*, which can manage serious problems in the best possible manner. B. Out of hours (after 5pm during working week/weekend/bank holiday) Please seek advice from your GP for minor complications. If you are not sure or if you think it is a serious problem, please come to Aintree Accident & Emergency department* for a review and Date Leaflet Approved: 26/11/2013 Issue Date: 06/12/2013 Review Date: 21/10/2016 further management. Page 2 of 3 Ref: 1596 Version No: 1 | *When you come to the hospital please bring this and any other relevant discharge documents that you may have been given at the time of discharge to help the A&E doctors to decide your management. University Hospital Aintree has a major Accident & Emergency Department and receives many Emergency Admissions requiring priority over available beds, which may on occasion mean that planned admissions have to be cancelled at extremely short notice ‘Oo B® If you require a special edition of this leaflet This leaflet is available in large print, Braille, on audio tape or disk and in other languages on request. Please contact the Equality and Diversity Department on: 0151 529 4969 Aintree University Hospital NHS Foundation Trust is not responsible for the content of any material referenced in this leaflet that has not been produced and approved by the Trust. Leaflet Lead Name: issue Date: 06/12/2013 Ref; 1596 Leaflet Name: Discharge Information Leaflet Date Leaflet Approved: 26/11/2013 Page 3 of 3 | Date Leaflet Developed: October 2013 Review Date: 21/10/2016 Version No: 1
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