Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0037, 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 | 2014-0037 |
| Deceased | Bertha Cray |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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: (1) Chief Executive Barts Health NHS Trust 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 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 The investigation into the death of Bertha CRAY, aged 84, was commenced on 4 January 2013 and concluded at the end of the inquest on 22 January 2014. The conclusion of the inquest was narrative (Copy attached). 4 CIRCUMSTANCES OF THE DEATH Bertha CRAY underwent an uppergastrointestinal endoscopy on 11 December 2012 at Newham General Hospital. During this procedure her oesophagus was perforated. She was subsequently transferred to The Royal London Hospital where conservative (nonsurgical) management was initially undertaken. She was placed ‘nil by mouth’ in order to allow the perforation to heal. On 15th December the ‘nil by mouth’ sign was noted to have been changed to a sign which indicated that she could take ‘sips’ of water. A jug of water had therefore been provided by the kitchen staff. At the inquest there was conflicting evidence regarding how the sign came to be changed. Evidence from the nursing staff was that the sign was doublesided (comprising ‘nil by mouth’ on one side and ‘sips’ on the other) and had inadvertently been turned. The family were clear that the signs were singlesided, of different colours and could not have been inadvertently changed. There was also conflicting evidence as to whether Mrs Cray did ingest any water; the nursing staff provided evidence that she had not taken any sips, whilst the family were clear that she had. Evidence from the treating surgeon indicated that ingestion of a small volume of water is unlikely to have significantly contributed to Mrs Cray’s death. An incident form was completed but did not demonstrate that any action had been taken as a consequence of the investigation. Mrs Cray subsequently deteriorated and, despite surgical intervention, died on 29 December 2012 from bronchopneumonia, which resulted from the perforation and surgical treatment. 1 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) On the account provided by the nursing staff, it is possible that inadvertent alteration of ‘nil by mouth’ signage could occur in the future, due to the apparent ease with which a doublesided sign can be turned and lack of action taken as a consequence of this clinical incident. (2) On the account provided by the family, the ‘nil by mouth’ sign was replaced by some other means. The cause of this alteration is unclear, owing to the focus of the incident form being the ‘doublesided’ account, provided by the nursing staff. As such, it is possible that there could be a recurrence of this incident, as the cause has not been elucidated. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of the Trust, 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 21 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, Mrs Cray’s family and The Care Quality Commission. 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 24 January 2014 Assistant Coroner R Brittain 2
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.
Peter Morris OBE Chief Executive Trust Offices Aneurin Bevan House 81 Commercial Road London E1 1RD HJT2647 Dr R Brittain Assistant Coroner for Inner North London Poplar Coroners Court 127 Poplar High Street London E14 0AE 14 March 2014 By special delivery Dear Sir Inquest - Ms Bertha Cray I write in response to your Regulation 28: Report to Prevent Future Deaths, dated 24 January 2014. I am pleased to inform you that the investigation into your concerns regarding the ease of alteration of double- sided ‘nil-by-mouth’ signs at the bedside, as well the cause of the alteration, has now been concluded. I am satisfied that this investigation has been sufficiently robust, in that we have scrutinised all relevant records, interviewed staff and have spoken with the family of Ms Cray to discuss their concerns and inform our investigation. During the investigation, qualified nursing staff confirmed that the use of double-sided ‘nil-by-mouth’/’sips of water’ signs at the bedside was not the usual practice in the Trust. In this particular case, ‘sips of water’ had been written on the other side of the sign. This practice will now stop and new signs issued with the same instruction on both sides, so there is no option to amend the signs by writing on them. As to the cause of alteration of the sign, the nurse involved was interviewed and explained that the ‘nil-by- mouth’ side of the sign was printed, whilst the writing on the other side was in green. This may explain why Ms Cray’s family gave evidence that there were two different signs. We have taken this as an opportunity to review our processes to enhance future care. The family has been informed of the outcome of the investigation and seemed reassured by the changes made by the Trust. Thank you for bringing your concerns to my attention. I hope you are assured I have taken them seriously and investigated them appropriately. Yours faithfully Peter Morris Chief Executive Barts Health NHS Trust Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross Hospital.
See every Prevention of Future Deaths report matching Barts Health NHS Trust, 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.