Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0264, written 18 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 | 18 Oct 2013 |
|---|---|
| Reference | 2013-0264 |
| Deceased | Jennifer Rushworth |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
Coroners
Manchester South 18 October 2013
Chief Executive
Stepping Hill Hospital
Poplar Grove
Stockport
SK2 7JE
RE: Jennifer Elsie RUSHWORTH (Deceased)
| recently heard the Inquest into the death of Jennifer Elsie Rushworth who died at
your hospital on 30 May 2013.
During the course of the Inquest | heard evidence from HR Consultant
Surgeon) who indicated a number of matters which caused me some concern and
which | would be grateful if you could look into please in order to prevent future
deaths occurring in similar circumstances.
The first of the issues that he raised was the fact that it is quite normal for cardiology
review to take anything up to six months to come through to the surgeon proposed to
operate on the patient. In this particular instance the first consultation with the
surgeon took place on 5 July 2012 and in view of her cardiac history he referred her
to the cardiologist for cardiac optimisation review. Report back from the cardiologist
came on 28 January 2013. It seems to me unsatisfactory that this length of time
should elapse for cardiology reviews in these circumstances.
Secondly the surgeon indicated that the booking of theatres and follow-up theretrom
is dealt with by the management and not from any input from the surgeons
themselves. [NM indicated that it was for this reason that there was a delay in
booking this lady in to surgery and that delay may have had a bearing on her
wellbeing at the time of surgery but more particularly during the recovery period.
Again | would have thought that an input from the surgeons would have been the
prime consideration that bed managers should be looking at when booking theatres,
etc.
Thirdly HE incicatea that there are simply not enough surgeons dealing with
this type of laparoscopic surgery and to deal with the number of patient’s requiring
their care. They are simply unavailable to perform these operations and therefore the
operations are later than would often be desirable and this can of course have quite
devastating effects.
an S Pollard U.B. Hons, Senior Coroner Coroner's Court
M { Igpor. Mottram Sti
anne Kearsley LIB. Bre Geran ; ‘abor, Mottram Street Stockport SR : m Street
Cha hensecacionn HE EE Eee eoectocteeteortn Stockport SK1 3PA
Area Coroner joanne.kearsley@stockport.gov.uk Telephanes nied aeseas
Finally he also indicated that they needed to be seeing this type of patient more
urgently and again they cannot do this simply because there are insufficient surgeons
available for the number of cases that they are expected to deal with.
On a separate issue completely | also heard evidence that the type of clips used to
clip blood vessels during the course of an operation have been changed since the ;
death of Mrs Rushworth. | would be grateful if you could confirm that this is the case
and also confirm whether or not the original clips were deficient in some way and
whether there is a need for further investigations as to the efficacy of the presently
used Clips.
This letter is written pursuant to Regulation 28 of the Coroners Regulations 2013 and
as such you are obliged to respond to it within a period of no more than 56 days.
A copy of this has been forwarded to the properly interested persons in this Inquest
as listed below and also to the Chief Coroner and the Coroner's Society Website. A
copy of your response will be similarly disseminated. | look forward to hearing from
you please within the specified time.
John S Pollard
Senior Coroner
CC to:
1. Pannone Solicitors (on behalf of family)
Stepping Hill Hospital
let Coroner's Office
hon
Coroners Manchester South 18 October 2013 Chief Executive Stepping Hill Hospital Poplar Grove Stockport SK2 7JE Our ref: JSP/KA/01346-2013 Your ref: RE: Jennifer Elsie RUSHWORTH (Deceased) | recently heard the Inquest into the death of Jennifer Elsie Rushworth who died at your hospital on 30 May 2013. During the course of the Inquest | heard evidence from BEE consuitant Surgeon) who indicated a number of matters which caused me some concern and which | would be grateful if you could look into please in order to prevent future deaths occurring in similar circumstances. The first of the issues that he raised was the fact that it is quite normal for cardiology review to take anything up to six months to come through to the surgeon proposed to operate on the patient. In this particular instance the first consultation with the surgeon took place on 5 July 2012 and in view of her cardiac history he referred her to the cardiologist for cardiac optimisation review. Report back from the cardiologist came on 28 January 2013. It seems to me unsatisfactory that this length of time should elapse for cardiology reviews in these circumstances. Secondly the surgeon indicated that the booking of theatres and follow-up theretrom is dealt with by the management and not from any input from the surgeons themselves. EEE reicated that it was for this reason that there was a delay in booking this lady in to surgery and that delay may have had a bearing on her wellbeing at the time of surgery but more particularly during the recovery period. Again | would have thought that an input from the surgeons would have been the prime consideration that bed managers should be looking at when booking theatres, etc. Thirdly indicated that there are simply not enough surgeons dealing with this type of laparoscopic surgery and to deal with the number of patient’s requiring their care. They are simply unavailable to perform these operations and therefore the operations are later than would often be desirable and this can of course have quite devastating effects. an S Pollard U.B. Hons, Senior Coroner Coroner's Court lor, anne Kearsley LI.B. Hons Grad. Dipie ee por A ane: A141 ava. 9009 Finally he also indicated that they needed to be seeing this type of patient more urgently and again they cannot do this simply because there are insufficient surgeons available for the number of cases that they are expected to deal with. On a separate issue completely | also heard evidence that the type of clips used to clip blood vessels during the course of an operation have been changed since the ; death of Mrs Rushworth. | would be grateful if you could confirm that this is the case and also confirm whether or not the original clips were deficient in some way and whether there is a need for further investigations as to the efficacy of the presently used Clips. This letter is written pursuant to Regulation 28 of the Coroners Regulations 2013 and as such you are obliged to respond to it within a period of no more than 56 days. A copy of this has been forwarded to the properly interested persons in this Inquest as listed below and also to the Chief Coroner and the Coroner's Society Website. A copy of your response will be similarly disseminated. | look forward to hearing from you please within the specified time. John S Pollard Senior Coroner CC to: 1. Pannone Solicitors (on behalf of family) 2 , Stepping Hill Hospital 3. Chief Coroner’s Office 4. Derek Winter
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