Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0112, written 13 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Mar 2014 |
|---|---|
| Reference | 2014-0112 |
| Deceased | Jean James |
| Coroner | Derek Winters |
| Coroner area | Sunderland |
| 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.
Derek Winter Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Ken Bremner Chief Executive City Hospitals Sunderland NHS Foundation Trust Kayll Road Sunderland SR4 7TP CORONER | am Derek Winter, Senior Coroner for the City of Sunderland 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. htto:/Avww. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 htto://www.legislation.gov.uk/uksi/2013/1629/partl/7/made INVESTIGATION and INQUEST On 10 January 2014 | commenced an investigation into the death of Mrs Jean James aged 75. The investigation concluded at the end of the inquest on 12.March 2014. The conclusion of the inquest was: - ‘Natural Causes Contributed to by Neglect’ CIRCUMSTANCES OF THE DEATH On 24 December 2013 Mrs James was admitted to the Acute Medical Unit from the Emergency Department. The attending doctor was to complete the admission documentation, the electronic venous thromboembolism assessment and the electronic prescription record. This began at 4:50pm and after five interruptions was completed at 6:20pm. The intention was to prescribe prophylactic Dalteparin, but this was not done. Although Mrs James was seen by a number of other doctors, the opportunity to prescribe Dalteparin was not taken. The pharmacy did raise a query about Dalteparin but that did not appear to be communicated so that the problem could be rectified. Mrs James died on 8" January 2014. Post Mortem examination has revealed the cause of Mrs James’ death as: - la Bilateral Pulmonary Thromboembolism; due to lb Deep Venous Thrombosis 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. — Civic Centre, Burdon Road, Sunderland, SR2 7DN Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sundertand.gov.uk/coroner 1) The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process. 2) The omission to prescribe prophylactic Dalteparin had not been subject to any effective review by a clinician or a nurse. 3) When the pharmacy raised a query, it was not communicated effectively. 4) Systems, forms, checklists, policies, procedures and protocols and compliance with them may not be sufficiently robust to deal with human factors. The failures prevailed without correction from 24 December until Mrs James’ acute deterioration and death on 8 January 2014. | heard evidence about the number of initiatives that were under way, including increased vigilance. However, | remain concerned that such steps may be insufficient to effect change in a more timely way. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 9 May 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - - Family - Irwin Mitchell Solicitors - DAC Beachcroft Solicitors - Risk Management, City Hospitals Sunderland NHS Foundation Trust - Care Quality Commission - Regulation 28 Archivist for Coroner Society of England and Wales iam 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. Dated this 13" day of March 2014 Senior Coroner for the City of Sunderland
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.
City Hospitals Sunderland INHS| NHS Foundation Trust Chief Executive: Ken W Bremner Sunderland Royal Hospital Kayll Road KWB/JH/VH Sunderland Tyne & Wear SR47TP 16 April 2014 T31: Fax: 0191 569 9642 Mr Derek Winter Senior Coroner for the City of Sunderland Room 2.108 Civic Centre Burdon Road SUNDERLAND SR2 7DN Dear. MeWinter Regulation 28 Report to Prevent Future Deaths | write in response to the correspondence received from you on 13" March 2014 following the inquest into the death of Mrs Jean James. | acknowledge the failures that led to Mrs James' death and offer my sincere apologies to her family. To mitigate against future risk the Trust has undertaken the following actions: 1) We have reviewed the hospital information system, known as MEDITECH V6 to find a solution to prevent further risk for patients who on assessment are at risk of developing a venous thromboembolism episode (VTE). The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk. The medical staff will be required to complete the prescription for the thromboprophylaxis medication at this point in the process. They will not be able to move out of the screen unless a drug has been prescribed or a rationale has been provided for not prescribing the medication, this may be required for patients with contraindicated co-morbidities. Additionally on the medication administration record (MAR) there will be an alert identified should the patient be at risk of VTE. This will be an extra prompt for nursing staff to ensure the prescribed medication is being administered. This system is currently in the test phase and | anticipate implementation by the end of May 2014. io Neurophysiology Department S #f/é ‘Ss Sunderland Eye Infirmary e ie Day Case Unit J 9 sage Chairman: John N Anderson QA CBE In association with the Universities of Newcastle, Sunderland and Northumbria www.sunderland.nhs.uk wzis24 The clinical teams will be alerted to this development by: e anall users electronic message e briefings within clinical teams | have also directed our Clinical Governance Department to undertake an audit of the system to ensure practice is embedded. 2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights key indicators regarding the patient's healthcare needs, and treatment plan. 3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions. ~~ 4) The Trust has a VTE policy based on NICE guidelines and we are currently reviewing the policy to encompass the technical changes made to the VTE assessment and prescribing process. We will hold a Trust wide clinical symposium in the autumn to ensure staff have the opportunity to discuss current issues regarding the management of patients at risk of VTE. i acknowledge that | cannot provide assurance that all actions have been resolved and request that you accept this letter as an interim position statement. Once ail of the actions are complete | will write to you again to provide confirmation and assurance. Please accept this letter as evidence that the organisation has reflected on and learnt from the events related to Mrs James’ death. Finally once again | would like to reiterate my apologies to Mrs James' family and offer sincere condolences. Yours sincerely KEN B —_—— Chief Executive
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