Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0034, written 24 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 | 24 Jan 2014 |
|---|---|
| Reference | 2014-0034 |
| Deceased | Lucy Goulding |
| Coroner | Karen Henderson |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) 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 THIS REPORT IS BEING SENT TO: Ms Marianne Griffiths, Chief Executive, Western Hospitals NHS Foundation Trust ~ 1; 2. BE President, Royal College of Paediatrics and Child Health — 3. Department of Health - CORONER lam Karen HENDERSON, assistant coroner for the coroner area of West Sussex 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 INVESTIGATION and INQUEST On 12" December 2013 | commenced an investigation into the death of Lucy Maria GOULDING, 16 years of age. The investigation concluded at the end of the inquest on 12" December 2013. The medical cause of death given was: 1a. Brain stem herniation 1b. Hydrocephalus 1c Pilocytic astrocytoma 2. My narrative conclusion was: Lucy Goulding died from brain stem death arising from raised intracranial pressure due to a benign cystic astrocytoma in circumstances where there was a delay in investigation and diagnosis and where deterioration went unrecognised, all of which could have affected the outcome. CIRCUMSTANCES OF THE DEATH Lucy Goulding presented with a relatively short history of headaches to her GP who diagnosed tension headaches or migraine. Her headaches worsened substantially and her mother dialled 999 and Lucy was admitted into hospital at or around 1400 on 26" June 2013. No formal assessment, investigation or management was undertaken for her headache during her time in hospital. A referral to the community mental health team was to be made the following day when the admitting doctors planned discharge. Lucy was transferred to the paediatric ward where neurological observations were not carried out. Lucy's headache persisted and worsened despite being treated with painkillers. She collapsed and had a cardiorespiratory arrest at or around 0300, 27" June 2013. She was intubated and ventilated and an emergency CT scan found a brain tumour, which was a benign cystic astrocytoma. Lucy was transferred to the neurosurgical unit at Southampton General Hospital for emergency treatment to relieve the pressure on her brain and to remove the benign tumour but she did not recover from her collapse at Worthing hospital and Lucy was confirmed dead at 21.12 on 27" June 2013 in the neurological ITU at Southampton General Hospital. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future death 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. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting paediatric patients as an emergency into Worthing Hospital 5981872.1 2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and outside normal working hours 3. Lack of national guidelines for assessment and investigation of headaches in children ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation: Worthing Hospital NHS Trust, Royal College of Paediatrics, and the Department of Health 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 24 March 2014. |, the coroner, may extend this 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 to the Chief Coroner and to the following Interested revs ll EE (mother)| (father) and to the local safeguarding board. | have also sent it to | | and| who may find it useful or of interest. lam 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. DATE: 24/01/2014 SIGNED: Karen Henderson Assistant Coroner West Sussex PP FeButo eck 1 5981872.1
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.
Formal Response to the Prevention of Future Deaths report under regulation 28 following the Inquest in the death of Lucy Maria Goulding. The Coroner identified the following concerns: 1. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting patients as an emergency into Worthing Hospital 2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and outside normal working hours. 3. Lack of national guidelines for assessment and investigation of headaches in children The Trust has responded to the Coroner’s concerns in the following way. The Trust undertook a thorough RCA into the case prior to the inquest. The action plan has been implemented and has been updated to take account of the coroners concerns. The appropriate standards from the Royal College of Paediatrics and Child Health document ‘Facing the Future’ are referenced throughout the document. 1. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting patients as an emergency into Worthing Hospital A primary recommendation of the original RCA strengthened the paediatric consultant's involvement in the three handovers between shifts. This had been established practice for the morning handover but not at other times. Support has been strengthened to provide direct consultant supervision of the afternoon handover and a telephone call from the consultant to the night team following their handover at the start of the shift. This call includes direct contact with the senior nursing staff. The following additional action points have been added to the action plan: a. An audit will take place in June 2014 to ensure whether the change in handover practice is embedded. b. Supervision of the SASG doctors through appraisal must take place in a timely way. c. The Responsible Officer (TT) has directed that the doctors who were involved in the LG case demonstrate the lessons learnt in their appraisals. 2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and outside normal working hours”. Context An Attending Physician system has been in place in Worthing paediatric department for several years and is well established ensuring new patients are reviewed directly on consultant provided ward rounds that occur daily including weekends. Thereis clearly protected time for the Attending Physician to review acutely ill children between 0900-1700 Monday to Friday and between 0900-1300 at weekends’. Direct consultant review at other times takes place on an as required basis as directed by the priorities identified at handovers or identified by the junior medical and nursing staff. Actions introduced in response to the LG SIRI and the Coroner's concern’s. Discussion of paediatric patients who are not in the ward areas e.g. patients that have been accepted but are still in Accident and Emergency has been incorporated into routine handovers. A baton bleep has been introduced for the Attending Physician so that they are readily contractible. The experience of the Recognition of the Critically Ill Child and High Dependency Care has been reinforced by the rotation of paediatric nursing staff to the Chichester site where there is greater exposure to HDU care.. 3. Lack of national guidelines for assessment and investigation of headaches in children The Trust has made extensive use of the teaching materials provided by the ‘Headsmart Campaign’ who provide targeted educational material on early recognition of the symptoms and signs of Brain Tumours in Children and Adolescents A joint meeting with the Local Area Team who provide oversight of primary care is scheduled for the <7 April 2014 to discuss ensuring smooth referral pathways for paediatric patients presenting with symptoms of headache or other symptoms that could reflect a brain tumour. The Trust will implement any appropriate National Guidance on this matter in a timely way. " Standard 5from Facing the Future, Standards for Paediatric Services (RCPCH 2011) states that ‘At least one medical handover in every 24 hours is led by a paediatric consultant (or equivalent)’. ® Standard 2 from Facing the Future, Standards for Paediatric Services (RCPCH 2011) states that ‘Every child or young person who is admitted to a paediatric department with an acute medical problem is seen by a consultant paediatrician (or equivalent staff, speciality and associate specialist grade doctor who is trained and assessed as competent in acute paediatric care), within the first 24 hours’. ® Standard 7 from Facing the Future, Standards for Paediatric Services (RCPCH 2011) states that ‘All general paediatric inpatient units adopt an attending consultant system usually in the form of the “consultant of the week” system’. Chief of Service - Women’s & Children’s Division 10" March 2014
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.