Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0195, written 28 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 | 28 Apr 2014 |
|---|---|
| Reference | 2014-0195 |
| Deceased | Robert Perkins |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Bristol NHS 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. North Bristol NHS Trust 2, Chief Coroner 4 | CORONER | am Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner Area of Avon 2 | 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. 3 | INVESTIGATION and INQUEST On 9th July 2013 | commenced an investigation into the death of Mr Robert Anthony Perkins age 69 years. The investigation concluded at the end of the inquest on 21st March 2014, The conclusion of the inquest was that the medical cause of death was Ia) Metastatic bladder cancer; Il Vertebral Fracture, Fall and the short-form conclusion was that the death was due ‘Natural Causes’. CIRCUMSTANCES OF THE DEATH ivr. Perkins was admitted to the Emergency Department of Frenchay Hospital on Sth June 2013 where he arrived at around 12:30 hours. He suffered with terminal cancer and had suffered a fall at home that morning. He was confused, agitated and complaining of posterior neck pain. On examination he had a large focal swelling over C4 - C6 with tenderness. A CT scan showed that he had suffered a compression fracture of C5 with marked angulation. Advice was sought from the neurosurgeons who considered that in the context of his terminal cancer with poor prognosis the fitting of a Philadelphia neck collar would be the appropriate sole treatment. It was noted that Mr. Perkins was due to be admitted to a hospice for terminal care. However, a bed was not immediately available at the hospice and Mr. Perkins was admitted to the ward overnight. Despite the instructions of the neurosurgeons no collar was fitted. Mr. Perkins was seen that evening by the consultant on the post-take ward round and he was seen again the following morning, the 6th June 2013, when still no collar had been fitted. That same morning Mr. Perkins was discharged to the hospice. He was seen by the Specialist Registrar in Medicine being escorted in a wheel chair by ambulance personnel. The Registrar, who in evidence, stated he had not seen Mr. Perkins before identified that Mr. Perkins should have a collar fitted and he was returned to the ward. The Registrar, who had neurosurgical experience, considered it to be unsafe for Mr. Perkins to be transferred without wearing a collar and decided to fit one as had been instructed by the neurosurgeons. There was no collar available on the ward and the Registrar spent some time visiting other wards and departments to obtain a Philadelphia collar but could not locate one in the hospital. Eventually he obtained a Miami J Collar and with assistance this collar was fitted and Mr. Perkins discharged to the hospice. When Mr. Perkins arrived at the hospice it was discovered that one part of the collar may have been fitted incorrectly causing him discomfort and it was removed. Mr. Perkins remained at the hospice where he died on 16th June 2013 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. — (4) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward. It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck. (3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge. (4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar. (5) The failure to properly immobilise the neck of patients with fractures of the cervical spine, whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and death. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 23rd June 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. | 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. 28th April 2014 Assistant Coroner
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.
North Bristol NHS Trust Trust Headquarters Soufhmead Hospital Bristol Southmead Road Westbury-on-Trym Bristol BS10 5NB Website: csumemossrac | 20 June 2014 Dr P Harrowing HM Assistant Coroner The Coroner’s Court The Courthouse Old Weston Road Flax Bourton BS48 1UL By Fax 01275 462749 Robert Anthony Perkins (deceased) 36 Kipling Road, Northville, Bristol DOB: 7/12 1943 DOD: 16/6/2013 | refer to the Regulation 28 report dated 28" April 2014 following the inquest into the death of Mr Perkins, which concluded on the 21st March 2014. From investigations it appears that whilst in the Emergency Department (ED) Mr Perkins was too agitated to wear a rigid collar and persistence in trying to put a collar on or even just wearing a collar would likely to have caused more harm and distress to him. Also the ED consultant felt it inappropriate to sedate Mr Perkins for the purposes of applying the collar, again due to the risks of harm from sedation. In the ED there were 2 separate attempts at putting a collar on - firstly a hard collar was attempted and then, later on, a Philadelphia collar (significantly more comfortable than hard collars thus better tolerated). Mr Perkins did not tolerate either. There was a clear decision made by the ED team that they should not persist further in applying a collar. What was not clear was how this was communicated across to the receiving medical team especially with | respect to the absolute need for the collar, if this could be tolerated by Mr Perkins, and the timing for attempting to reapply the collar. Following review, the ED matron had discussed this communication failure with the nursing team concerned. It is clear that communication of these issues is vital to prevent a recurrence of a similar case. It is agreed that communication should include, where there is a failure to apply a rigid collar in the ED, the reasons why the collar was not applied and the nursing aspects for the neck in the interim and when a reattempt at applying the collar should occur. Since the move to the new hospital at Southmead a change has occurred in process regarding overall responsibility for patients. Now Acute Admissions Unit (AAU) consultants are in charge of the medical intake 24/7, (previously the on call consultant was in charge in lieu of an acute physician) so there is a clearer line of responsibility — there is an AAU I consultant (i.e. acute physician) on site between 8 am and 10 pm and on call overnight as Peter Rilett A University of Bristol Teaching Trust Andrea Young Chairman A University of the West of England Teaching Trust Chief Executive well. The effect of this is that there is much less variance in terms of clinicians with overall responsibllity, now only 8 rather than the previous 24 clinicians. Following the inquest the Clinical Director (CD) of the Medicine Directorate discussed this case will his neurosurgical colleagues, in particular awareness and understanding regarding the use of collars. | enclose a hard collar safety alert dated October 2011. The CD will re- publicise this issue by sending this alert out again to the Medical Directorate, and to other CDs to ensure that there is Trustwide distribution in the next few days and also include it in future medical induction of new junior medical staff (the next one will be in August 2014) The accessibility of rigid collars for the purposes of cervical immobilisation is something that is also being readdressed now since the move into the new Brunel building. A place for central storage of these devices is being looked for within the Emergency Zone. By creating a single area for the location of these devices it should make it easier to know where to find a collar when the device is needed. It is anticipated that this action should be completed by the end of June 2014. The regulation 28 report will also be reported on in part B of the Medical Directorate’s clinical governance agenda on 26 June 2014. From here it will be decided on whether any further action needs to be taken. Following this, it is likely that a further notification will be made to the directorate’s medical teams to ensure that they are all familiar with the need to review plans for cervical immobilisation when a patient is admitted with a cervical neck injury and the location of the rigid collar devices. In conclusion, Mr Perkins was an exceptional case in the Medical Directorate, i.e., a dying man who was confused and difficult to manage who did not have a collar fitted in ED, for the reasons explained above. However, | agree it was fortuitous he did not suffer further disability, that his management was substandard in AAU, and | trust the implementation of the above will prevent a recurrence of these or similar issues in the future. Chief Executive Peter Rilett : A University of Bristol Teaching Trust Andrea Young Chalrman A University of the West of England Teaching Trust Chief Executive
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