Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0366, written 16 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2013 |
|---|---|
| Reference | 2013-0366 |
| Deceased | Cynthia Fretwell |
| Coroner | Jane Gillespie |
| Coroner area | Nottinghamshire |
| Category | Community health care and emergency services 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) | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS \ THIS REPORT IS BEING SENT TO: 1. The Hama Medical Centre | 2. RRR paughter of Cynthia Fretwell 3. Dr Area Medical Director — NHS Commissioning Board Derbyshire and Nottinghamshire 5. Ministry of Justice 6. Chief Coroner 7. Mr Derek Winter, HM Coroner for Sunderland (for record-keeping | purposes) | CORONER | am Jane Gillespie, Assistant Coroner, for the coroner area of Nottinghamshire. CORONER’S LEGAL POWERS | make this report pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 16" October 2013, | commenced an investigation into the death of Cynthia Fretwell, aged 84. The investigation concluded at the end of the inquest on 12"" November 2013. The conclusion of the inquest was: On the 12" day of February 2013 Cynthia Fretwell died as a result of peritonitis as a result of an infected gall bladder which had not responded to treatment by antibiotics. CIRCUMSTANCES OF THE DEATH Mrs Fretwell had a history of abdominal pain and on 8" February 2013, she was admitted to the emergency department of the Queens Medical Centre in Nottingham. She had been diagnosed by her GP as having obstructive jaundice following a home visit. Upon admission Mrs Fretwell, was treated with antibiotics as the working diagnosis was of an inflamed gall bladder and localised peritonitis. Mrs Fretwell’s condition | improved and she was discharged on 9"" February 2013 to continue a course of antibiotics in the community. On 11'° February 2013, Mrs Fretwell’s GP visited her at home as she was feeling unwell. It was noted that she was suffering from a temperature, tenderness in her gallbladder and jaundice. Mrs Fretwell was not admitted to hospital. On 12.02.13 Mrs Fretwell’s family contacted her GP again as Mrs Fretweil was still not well. A telephone consultation took place but Mrs Fretwell was not seen in person by the GP. Mrs Fretwell remained at home and was not admitted into hospital. She died at | 11.25pm that evening. CORONER’S CONCERNS | 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) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, | had concerns about the following aspects: During the course of the inquest the evidence revealed matters giving rise to concern. In (a) The inability of reception staff to interrupt a GP during surgery for the purposes | of alerting and informing the doctor of a change in the patient's condition following a telephone referral. | (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. | (2) A full assessment of the patient's mental capacity in a situation where they are refusing medical treatment or admission to hospital. | (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. In the course of oral evidence taken at the inquest on the 16.10.2013, | was informed of | changes that had been instituted by the Hama Medical Centre since the death of Mrs Fretwell which would address these concerns. | adjourned the inquest on 16” October 2013 to provide an opportunity to the Hama Medical Centre to commit the detail of changesto writing. | asked that a report to be filed by 4pm on 30" October 2013 and the | matter was re-listed on 12'" November 2013. | | received a report from the Hama Medical Centre dated 21“' October 2013. | was satisfied from the contents of that letter and its attachments that matters i(a) & (b) of the concerns above had been addressed. However, there was no reference to the | remaining issues of concern which had been identified. In the circumstances therefore, | consider the response inadequate and feel my duty to report has been invoked. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | believe you 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 10" February 2014. |, 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 a... Fretwell’s daughter and ei Medical Director for the NHS Commissioning Board in Nottinghamshire and Derbyshire. This organisation has responsibilities for overseeing primary care for patients. | |am also under a duty to send the Chief Coroner a copy of your response. i 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. 16.12.13 y _ ~
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.
Hama Medical Centre 11 Nottingham Road, Kimberley, Nottingham NG16 2NB Telephone 0115 9382101 - Fax 0115 9459208 i alcentre.co.uk 14° February 2014 Dear Miss Gillespie, Re: Cynthia Fretwell (deceased) dob 28.6.1928 Late of 7 Croft Crescent, Awsworth, Nottinghamshire. Further to Regulation 28 report to prevent future deaths dated 19.12.2013, the Practice has discussed this case as a Significant Event. The discussions have taken place during Medical meetings on several occasions, in the presence of GP’s, Practice Nurses, Reception Manager and Practice manager. As a result of our discussions, the following steps have been taken: L. 6. The Practice has updated its MENTAL CAPACITY ACT 2005 POLICY. This is saved on the ‘ shared drive ‘ for all the staff to access it as necessary. See attached. A summary of the Mental capacity Act 2005 in also saved on the ‘shared drive’ for more detailed reference. Telephone Consultation Protocol has been updated and copy of this has been submitted to your office and been accepted by yourself. We have discussed the Mental Capacity Act during our Medical Meetings so that we are all updated on it. Particular attention has been paid to sections relating to the Principles of the Act, Purposes of the Act and Best interests, as highlighted in the copy of summary of Mental Capacity Act attached. Attention is also paid to 5 core principles, basic recording, assessment of capacity and assessment of capacity checklist in the Practice’s Mental capacity act policy. have previously attended Protected Learning time event on 23.5,2013 on Safeguarding Children and vulnerable adults, Mental Hama Medical Centre is the trading name of HMC (Kimberley) Limited Registered No: 8244108 This practice is a member of the Nottingham West Clinical Commissioning Group, a group of local NHS practices, making local decisions for local people. Nottingham West Clinical Commissioning Group Hama Medical Centre 11 Nottingham Road, Kimberley, Nottingham NG16 2NB Telephone 0115 9382101 - Fax 0115 9459208 Website: wu S. Capacity Act and PREVENT. This event addressed the principles and application of the Mental Capacity Act, amongst other issues. They will continue to keep themselves updated by attending appropriate future courses. vill be attending such course in the very near future. The Practice staff have attended a course to learn about Mental capacity Act in 2009 and will update themselves with e-learning this subject on ‘blue stream academy’. The Practice answers your queries in 1c, 2 and 3 as follows: Ic: The Practice will adopt a very low threshold for home visiting. This would especially be so in a patient who has not been seen face to face previously, in the elderly , if the illness was on going or if there was any doubt whatsoever about the nature of medical problem on the phone. 2. A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital will be made in accordance with the guidelines in the Practice’s mental capacity policy attached. If the clinical situation warranted hospitalisation GP would, with the help of the family, encourage the patient to go into hospital. If the patient refused, GP would reinforce the need for hospitalisation and the serious consequences of not doing so. As long as the patient had mental capacity as judged per protocol attached, their choice would be respected. If the patient is assessed as lacking mental capacity the GP would with the help of the family make a choice that was in the patient’s best interest. Please refer to the copy of summary of Mental Capacity Act and Policy attached. 3. A full and proper documentation of the discussions that would take place between GP, the patient/patient’s family in these circumstances would be made in patient notes. Please refer to basic recording in the Mental Capacity Act 2005 Policy. Hama Medical Centre is the trading name of HMC (Kimberley) Limited Registered No: 8244108 This practice is a member of the Nottingham West Clinical Commissioning Group, a group of local NHS practices, making local decisions for local people Nottingham West Clinical Commissioning Group Hama Medical Centr 11 Nottingham Road, Kimberley, Nottingham NG16 2NB Telephone 0115 9382101 - Fax 0115 9459208 Website: www. aleentre.co.uk We hope the steps outlined above meet with your satisfaction. We will be very pleased to engage with yourself on any matter you feel is not addressed. Yours sincerely, Hama Medical Centre is the trading name of HMC (Kimberley) Limited Registered No: 8244108 This practice is a member of the Nottingham West Clinical Commissioning Group, a group of local NHS practices, making local decisions for local Nottingham West Clinical Commissioning Group
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