Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0189, written 29 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 | 29 Apr 2014 |
|---|---|
| Reference | 2014-0189 |
| Deceased | Stephen Widman |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay & South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 Recipients This report is being sent to: Chief Executive, Torbay Hospital Secretary of State, The Ministry of Health Coroner I am IAN MICHAEL ARROW, Senior Coroner for the area of Plymouth, Torbay & South Devon 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 Investigation and Inquest On the 7th May 2013 I commenced an investigation into the death of Stephen Anthony Allardice Widman aged 63. The investigation concluded at the end of the Inquest on 23rd April 2014 The cause of death was found to be: 1a Sepsis 1b Urinary tract infection with pyelonephritis 1c Carcinoma of excision after chemo-radiotherapy; urethral tear noted and repaired. the rectum (operated 13.3.13.) abdominal-perineal The conclusion of the Inquest was that a Narrative was recorded namely: During ongoing treatment the deceased was catheterised on several occasions. Infection developed. The deceased deteriorated and died in Torbay Hospital, Torquay on the 26th April 2013. Circumstances of death The deceased had been suffering from carcinoma of the rectum. That was treated. The deceased had been catheterised and was catheterised repeatedly thereafter. On the balance of probability a catheter was inappropriately placed. Infection developed. The deceased was weakened through contraction of pneumonia. Coroner’s concerns The matters of concern are as follows: 1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department. 2. The deceased was catheterised too frequently without the management of a urologist. Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number. Action should be taken Evidence was received that a Consultant could issue a vulnerable patient (particularly patients who are vulnerable because of cancer treatment) with a card to present at an Accident and Emergency Department which would read to the effect “I am vulnerable because .... please contact x on my behalf”. The evidence received was that this would be particularly helpful during weekends. The issue of such cards should be at the discretion of the Consultant having care of the patient. I would ask Torbay Hospital and the Minister to consider the appropriateness of the issue of such cards. Action should betaken In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation 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, 24th June 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. Copies and publication I have sent a copy of my report to The Chief Coroner and to the following interested persons Dittisham, South Devon I am under a duty to send the Chief Coroners 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 to the Chief Coroner I.M. ARROW Senior Coroner – Plymouth, Torbay & South Devon Dated 29th April, 2014
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