Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0004, written 7 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jan 2014 |
|---|---|
| Reference | 2014-0004 |
| Deceased | James Withers |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside Hospital NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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:
Chief Executive Tameside Hospital NHS Foundation Trust
1
CORONER
I am John Pollard, senior coroner, for the coroner area of Manchester South
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.
3
INVESTIGATION and INQUEST
On 29th January 2013 I commenced an investigation into the death of James Hadfield
Withers (dob 16/8/26).The investigation concluded at the end of the inquest on 19th
September 2013.
The conclusion of the inquest was “In October 2012 Mr Withers was diagnosed as
suffering a recurrence of carcinoma of the bowel. He was admitted to hospital for a
resection of the affected area on the 11th December 2012: Immediately post operatively
he was treated on the ITU and made very good progress. He was then transferred to the
surgical ward and his condition generally deteriorated thereafter: During his time on this
ward and after his return to the ITU there were a number of occasions of poor
communication with the family of the deceased; he was thought to be classified as
DNAR when a doctor mistook him for another patient; little or no explanation was given
to the family as to his actual DNAR status and/or as to why it was deemed appropriate
as to why and when it was decided to take him off ventilation. On the 27th January 2013
he died as a result of his diseased heart, contributed to by the stress of the necessary
operation to remove the cancer”
The medical cause of death was 1a Congestive Cardiac failure 1b left ventricular failure
1c valvular heart disease (aortic stenosis) 2. Open extended right hemi-colectomy for
invasive colonic adenocarcinoma .
4
CIRCUMSTANCES OF THE DEATH
The circumstances are apparent from the conclusion as outlined above
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. There was a delay of five days between the Cardiologist being requested to see
the patient and actually attending the patient
2. Various of the medical/nursing notes appear to have gone missing
1
3. The patient’s DNAR status was fixed without any reference to/discussion with
his family. Whilst it is appreciated that this decision is for the doctor alone, good
practice would require that the family be kept up to date with all such decisions
4. One of the doctors admitted that he had assumed an incorrect DNAR status
based on the fact that he had two separate pieces of paper in his pocket and
had looked at the wrong one.
5. There was generally poor communication between nursing and medical staff
(inter se) and between medical/nursing staff and the family of the patient.
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 8th March 2014. 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 and to the following Interested
Persons :-
who may find it useful or of interest.
(daughter of the deceased). I have also sent it to CQC
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
7th January 2014 John Pollard
HM Senior Coroner
2
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