Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0145, written 2 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Apr 2014 |
|---|---|
| Reference | 2014-0145 |
| Deceased | John Dodd |
| Coroner | Andrew Thompson |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Dudley Group NHS Foundation Trust |
| 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.
Smethwick Council House
High Street
Smethwick
F ; West Midlands
Robin J. Balmain
B66 3NT
H.M. SENIOR CORONER
BLACK COUNTRY CORONER'S DISTRICT js FE
(SANDWELL ° DUDLEY * WALSALL * WOLVERHAMPTON E :
Metropolitan Borough Councils) po |
Date: 02 April 2014 Our Ref: RJB Your Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Medical Director,
Dudley Group of Hospitals
Russells Hall Hospital
Pensnett Road
Pensett
Dudley
DY12HQ
1. CORONER
I Andrew Paul Thompson am the Assistant Coroner for the Black Country Coroners
Jurisdiction
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 26 March 2014 at Dudley Coroners Court I concluded the inquest into the
circumstances surrounding the death of Mr John Dodd.
4. CIRCUMSTANCES OF THE DEATH
The Deceased died of a Retroperitoneal Haemorrhage at Russells Hall Hospital, on 21
April 2013, having been admitted 20 April 2013 through A&E. He had been seen in
A&E at Russells Hall Hospital on 16 April 2013 a few days prior to his final
admission and sent home.
5. CORONERS CONCERNS
The MATTERS OF CONCERN are as follows :-
The deceased was on Warfarin but the INR was not checked on 16 April 2013
despite the degree of pain and the history of fall.
This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm
There was a rise in temperature of nearly 1 degree on the afternoon of 16 April
2013 documented by the IMPACT team which was not reported to the medical
staff. This was against a background of paracetamol being administered. It
was the evidence off that he would have wanted to know about this
and would have wanted the patient reassessed medically prior to the actual
discharge from the department. This did not happen, Mr. Dodd having been
declared medically fit for discharge prior to the referral to the IMPACT team.
There was a considerable delay on the night of the 20 April between the
arrival of Mr. Dodd in A&E and his first assessment by_a medically qualified
member of staff vis: 20:44 - 00:23. It was the evidence of MB tat this was
inappropriate, and clearly led to a delay in investigation and diagnosis.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I 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 the
report, namely by Wednesday 28th May 2014.
COPIES and PUBLICATIONS
I have sent a copy of my report to the Chief Coroner and to the following interested
Persons :
None
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
Ce response, about the release or the publication of your response by the Chief
C&roner.
A. P. Thompson
Assistant Coroner
BAP
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.
The Dudley Group INHS NHS Foundation Trust Ref: RJB Black Country Coroner's District In the matter of Mr John Dodd Response to Regulation 28 Report to Prevent Future Deaths 1. | DT akc this submission in my capacity as Medical Director at The Dudley Group NHS Foundation Trust. 2. Facts The facts are set out in the enclosed chronology. 3. The following issues have been raised by H.M. Coroner The deceased, (Mr John Dodd) was on warfarin but the INR was not checked on 16" April 2013 despite the degree of pain and history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a back ground of paracetamol being administered. It was the evidence of EE eat he would have wanted to know about this (ii above) and would have wanted the patient assessed medically prior to the actual discharge from the department. This did not happen. There was considerable delay on the night of the 20" April between the arrival of Mr Dodd in A&E And his first assessment by a medically qualified member of staff vis: 20:44-00:23 4. Current practice at The Dudley Group NHS Foundation Trust International normalised ratio (INR) is not routinely checked in all patients with the clinical presentation of the patient on 16/04/13, i.e. with non-truncal injury or head, lacking visible swelling or bruising and having vital signs within normal limits. A rise in temperature between 36.6 (at 1007) and 37.5 at (1434) would not always require a referral to medical staff by the nurse if the patients vital signs fall within acceptable parameters based on the National Early Warning System (NEWS) as The Dudley Group INHS| NHS Foundation Trust recommended by the Royal College of Nursing, Royal College of Physicians and the College of Emergency Medicine. The consultant responsible is made aware of any patient whose vital signs are outside of acceptable parameters, based on NEWS. All staff are trained to recognise abnormal vital signs using the NEWS. The current clinical electronic information system indicates to the doctor any patient whose vital signs fall outside normal parameters. However, the consultant must access the individual patient record in order to see the alert. 5. Actions to Prevent Future Deaths The following actions together address H.M Coroner's concerns I-V above: e A written guideline will be developed to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants, such as warfarin. e The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff. e The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review when presenting to the Emergency Department. Additionally; e The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patient's vital signs fall outside normal parameters. e Allof the above actions will facilitate a reduction in the delay highlighted in points I-IV above. 6. Review of Actions The lead nurse and consultant in the Emergency Department will be responsible for ensuring actions changes are implemented. The first three actions will be carried out within two months and the fourth within four months. The Dudley Group INHS| NHS Foundation Trust A report will be presented by the Medical Director & Director of Nursing to the Clinical Quality, Safety & Patient Experience Board Sub-Committee, which will be responsible for ensuring that actions are implemented.
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