Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0031, 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 | 2014-0031 |
| Deceased | Mone White |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North West London Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
i, _ North London c. Court, Her Majesty’s Coroner for the 29 Wood Steet Northern District of Greater London Barnet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: i. Northwick Park Hospital Watford Road, Harrow, Middlesex, HA1 3UJ 2. Department of Health Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 | CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 | INVESTIGATION and INQUEST On the 12 July 2012 | opened an inquest touching the death of Mone Jahni Karl White, aged 3 years old. The investigation concluded at the end of the inquest on the 17" January 2014. The conclusion of the inquest was “Narrative verdict”, the medical case of death was ;1a Acute heart failure, 1b Asthma/ chest infection, and under paragraph 2 Dilated cardiomyopathy. 4 | CIRCUMSTANCES OF THE DEATH Mone suffered with dilated cardiomyopathy, probably caused by a viral infection. Mone was under the care of the Royal Brompton hospital and had repeated episodes of illness requiring hospital treatment precipitated by infections. The Royal Brompton Hospital had in 2010 produces a document giving guidance to those who may come into contact with Mone. A copy was sent to Northwick Park / Hospital and the London Ambulance Service and Mone’s parents had a copy. Mone was admitted on the 5"" July 2012 having been brought into Northwick Park Hospital by ambulance with an episode of illness. The doctors who treated Mone had not seen this document despite there being a copy in the medical notes. - Her Majesty's Coroner for the a Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) On the 7" July 2012 Mone’s condition was stable at the time of the ward round in the morning but had deteriorated by 10.50. Doctors attended and began to treat Mone. Shortly before 11.25 Mone became unresponsive and despite attempts it was not possible to save his life. lf Mone had been referred and been accepted by the Royal Brompton Hospital on the 5° or the 6" July 2012 it is likely that he would not have died when he did. 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) The development of a flag system for patients, under the care of specialist hospitals, with special clinical requirements to ensure that advice about clinical care is brought to the attention of all treating clinicians. 6 | 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 14" March 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Representative of members of the family. 1 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 thp release or the publication of your response by the Chief Coroner. 9 | 21 Janyary 201
2 responses 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.
aR From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall Lond POCI_838141 SWIA 2S Tel: 020 7210 3000 Mr A Walker Mb-sofx@dh gsi.gov.uk Senior Coroner North London Coroners Court 29 Wood Street Barnet EN5 4BE -5 MAR 9nd ex Am. Weller Thank you for your letter following the inquest into the death of Mone Jahni Karl White. In your report you conclude that the medical cause of death was acute heart failure, asthma/chest infection and dilated cardiomyopathy. Mone was a three year old boy who suffered with dilated cardiomyopathy and was under the care of the Royal Brompton Hospital. He had repeated episodes of illness requiring hospital treatment. In 2010 the Royal Brompton Hospital produced a guidance document for those who might come into contact with Mone and sent copies to Northwick Park Hospital, the London Ambulance Service and Mone’s parents. On 5 July 2012 Mone was taken ill and brought by ambulance to Northwick Park Hospital. The doctors treating him did not see the guidance document despite there being a copy in the medical notes. On the 7 July 2012, Mone’s condition deteriorated and although doctors attended and treated him he later became unresponsive and it was not possible to save his life. You comment that had Mone been referred to the Royal Brompton Hospital on the 5th or 6th July it is likely he would not have died when he did. You also ask that we consider: e The development of a flag system for patients, under the care of specialist hospitals, with special clinical requirements to ensure that advice about clinical care is brought to the attention of all treating clinicians. I am very grateful that you have brought this important patient safety issue to my attention. It appears that there was already an effective system in place to ensure that important information was sent to relevant organisations likely to come into contact with Mone, but that this was not seen or acted upon by the clinicians treating Mone at Northwick Park Hospital. I note that you have sent a copy of this Regulation 28 report to the Northwick Park Hospital. I anticipate that they will be able to comment in more detail on the reasons why the doctors treating Mone had not seen the guidance document prepared by the Royal Brompton Hospital and I would expect them to properly respond to the issues concerning local care procedures and standards, which you have raised. ’ I can also advise that the General Medical Council (GMC) is the body responsible for setting good medical practise standards for doctors. Within the GMC code of practise, “Good Medical Practise” there is a section covering the continuity and coordination of patient care which makes clear that all relevant information should be shared with colleagues involved in a patient’s care. I’ve quoted the relevant extract below for your information: Continuity and coordination of care 44, You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers, This means you must: a. share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers b. check, where practical, that a named clinician or team has taken over responsibility when your role in providing a patient’s care has ended. This may be particularly important for patients with impaired capacity or who are vulnerable for other reasons. 45. When you do not provide your patients’ care yourself, for example when you are off duty, or you delegate the care of a patient to a colleague, you must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient. With regard to developing a flag system in specialist hospitals to ensure that advice about clinical care is brought to the attention of all treating clinicians, I consider that aes Department of Health this is a matter for attention at local, rather than national level. The NHS Trust concerned needs to ensure they have a system in place whereby all relevant, and available, information is routinely accessed and acted upon. I would of course be happy to consider any national learning that may come about as a result of this sad case. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mone’s death to my attention. SOs, svawey Sa Pg JEREMY HUNT
Peter’ Worthington, Chairman The North West London Hospitals [7i59 David McVittie, Chief Executive and na Merger Transaction Director Tee Tel: 020 8869 2005 Trust Headquarters Fax: 020 8864 5511 Northwick Park Hospital Email: nwlh-tr.trust@nhs.net Watford Road Harrow Middlesex HA1 3UJ 15" April 2014 Mr Andrew Walker Senior Coroner North London-Coroners Court 29 Wood Street Barnet EN5 4BE Dear Mr Walker Re. Regulation 28 Report to Prevent Future Deaths Further to the receipt of the above, | am able to confirm that The North West London Hospitals NHS Trust (NWLHT) has developed a flagging system for patients under the care of specialist hospitals with specialist clinical requirements. This will ensure the advice about the clinical care of these children is brought to the attention of all treating. clinicians. The flagging system has been devised in partnership with the Consultant Paediatricians and the IT Department. The process has been documented and is supported by a standard operating procedure which clearly defines the purpose, scope, duties, responsibilities and process. The need for and implementation of the flagging system has been discussed widely within the Paediatric Directorate and was presented at our most recent Governance meeting. | am able to confirm that the flagging system has been implemented and further work is underway to improve its functionality. | am happy to provide further detail should this be required. Yours sincerely CA ME David McVittie Chief Executive and Merger Transaction Director
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