Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0025, written 21 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 | 21 Jan 2014 |
|---|---|
| Reference | 2014-0025 |
| Deceased | Christine Nutbeam |
| Coroner | Peter Bedford |
| Coroner area | Berkshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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
THIS REPORT IS BEING SENT TO:
1. Chief Executive, Wexham Park Hospital, Slough
2. Chief Executive, St. Peter’s Hospital, Chertsey, Surrey
1
CORONER
I am Peter James Bedford, senior coroner, for the coroner area of Berkshire
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 7th August 2013 I commenced an investigation into the death of Christine Nutbeam,
then aged seventy six years. The investigation concluded at the end of the inquest on
16th January 2014. The conclusion of the inquest was a narrative verdict, the medical
cause of death being Pneumonia and Adult Respiratory Distress Syndrome due to
Aspiration during a Debridement Operation for an infected injury to the right leg. A copy
of the Narrative Verdict is attached.
4
CIRCUMSTANCES OF THE DEATH
1. Mrs Nutbeam was struck by a car in the car park of Sainsbury’s Supermarket in
Cobham, Surrey on 28th June 2013 while a pedestrian. She suffered a
degloving injury just above her right ankle but no broken bones. She was
treated in St. Peter’s Hospital with a follow up appointment with plastic surgeons
at Wexham Park Hospital to treat the leg wound.
2. On 9th July, Mrs Nutbeam attended St. Peter’s Hospital with abdominal
discomfort and vomiting. Staff at St. Peter’s rearranged an appointment that
Mrs Nutbeam had for the same day, 9th July, at Wexham Park Hospital, the new
appointment being two days later.
3. Mrs Nutbeam attended Wexham Park Hospital on 11th July and the following
day was taken to theatre for a debridement procedure as the leg wound had
become infected. Treating Clinicians at Wexham Park Hospital were not made
aware of the recent vomiting episodes and treatment at St. Peter’s Hospital on
9th July nor that, after admission to Wexham Park Hospital, she had continued to
vomit. There was no record in the nursing notes.
4. During the surgery at Wexham Park Hospital on 12th July, Mrs Nutbeam vomited
and aspirated. Despite subsequent treatment in Intensive Care, she passed
away and a post mortem examination revealed pneumonia superimposed on
Adult Respiratory Distress Syndrome which the Pathologist concluded was a
direct consequence of the aspiration following the debridement procedure.
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
(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the
recent admission, treatment and symptoms even though they were on notice that Mrs
Nutbeam had a follow up appointment at Wexham Park Hospital some two days later
because they arranged that appointment. Concern is the apparent lack of any
procedure to allow information to be transferred between different Trusts in different
Counties. There was no letter given to Mrs Nutbeam to accompany her to the
subsequent appointment.
(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward
shortly before her debridement procedure, there is no reference in the nursing notes and
this information was not made known to the Anaesthetist nor Surgeon. The fact that she
was vomiting prior to a surgical procedure should have been a matter of serious
concern.
(3) The evidence given at the Inquest was that if the Anaesthetist/Surgeon had been
aware of the vomiting symptoms, the procedure would have been deferred to investigate
the cause of the vomiting. This may have prevented aspiration during the surgery.
(4) It was also given in evidence at the Inquest that, when the Anaesthetist visited Mrs
Nutbeam prior to the surgery and explained the procedure, the risks and took her
consent, he did not ask her if she had vomited within the last twenty four hours. The
evidence was that this is not a standard question to ask of patients ahead of surgery.
The question is posed as to whether this should become a standard question that is
asked of patients prior to going to procedure as, if it had been asked on this occasion,
the lack of information from St. Peter’s Hospital and the absence of any reference to
vomiting in the nursing notes would still have come to the attention of the treating
Clinicians. Should this become a training issue?
6
ACTION SHOULD BE TAKEN
In my opinion urgent action should be taken to prevent future deaths and I believe your
organisation has 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 Wednesday 19th 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 Mrs Nutbeam’s family.
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.
21st January 2014
9
P.J. Bedford
H.M. Senior Coroner for Berkshire
2
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