Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0138, written 24 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 | 24 Mar 2014 |
|---|---|
| Reference | 2014-0138 |
| Deceased | Phyllis Barnes |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Frimley Park Hospital NHS Trust |
| 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. Mr Andrew Morris, Chief Executive, Frimley Park Hospital NHS Trust
2.
, Clinical Lead, North East Hampshire & Farnham Clinical
Commissioning Group
3. Professor Norman Williams, President, Royal College of Surgeons
1
CORONER
I am Karen HENDERSON, assistant coroner for the coroner area of Surrey
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 March 2014 I commenced an investigation into the death of Phyllis Barnes, 82 years of age. The
investigation concluded at the end of the inquest on. The medical cause of death given was:
1a. Peritonitis
1b. Anastomotic Leakage Post Anterior Resection for Carcinoma of the Colon
1c
2.
My narrative conclusion was:
Mrs Barnes died from a recognised complication of necessary surgery where there was a
delay in the recognition of the severity of her symptoms which resulted in a delay in
treatment which could have affected the outcome
4
CIRCUMSTANCES OF THE DEATH
Mrs Barnes underwent an elective laparoscopic anterior resection for carcinoma colon on 11th
April 2013. She was discharged home on the enhanced recovery programme for laparoscopic
procedures on 15th April 2013. Mrs Barnes became unwell with vomiting on or shortly after
discharge from hospital and her daughter called her GP practice, the Downing Street Group
Practice, on the day of discharge because of the vomiting and anti-emetics were prescribed.
The Nurse Practitioner from the surgical department called as routine on the 16th April 2013 but
reassured Mrs Barnes that ‘it takes time’ when she commented on vomiting and feeling unwell.
It is unclear whether there was a subsequent phone call as promised. Mrs Barnes continued to
vomit and the GP visited at her daughter’s request but no treatment was instituted or referral
made back to hospital. Mrs Barnes continued to deteriorate and she was readmitted as an
emergency on 18th April for repair of an anastomotic leak arising from the original procedure but
died of these complications at 0530 on 19th April 2014.
5
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
The MATTERS OF CONCERN are as follows:
1. Failure of visiting General Practitioner to appreciate the seriousness of Mrs Barnes condition in
view of her recent operation and persistent symptoms
2. Postoperative nurse-led telephone consultation for the enhanced recovery programme for
laparoscopic surgery’ appears to have been superficial and perfunctory with doubts over a further
telephone follow-up as promised
3. There was no formal communication or opportunity for Mrs Barnes’s daughter to relate her
mother’s condition to the GP or the Nurse Practitioner
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your organisation:
Frimley Park Hospital, Royal College of Surgeons, and Clinical Commissioning Group, 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 24th
March 2014. I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;
(daughter). I have also sent it to
and
who may find it useful or of
interest.
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
DATE: 24-Mar-2014 SIGNED: Dr K Henderson
RT3935
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
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