Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0216, written 8 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2014 |
|---|---|
| Reference | 2014-0216 |
| Deceased | Frank Pope |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Whittington Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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) Chief Executive The Whittington Hospital NHS Trust (2) The Partners, Northern Medical Centre, 580 Holloway Road, London 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 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 The investigation into the death of Frank POPE, aged 65, was commenced on 18 December 2013 and concluded at the end of the inquest on 2 May 2014. The conclusion of the inquest was narrative 4 CIRCUMSTANCES OF THE DEATH Mr Pope had a background medical history of ischaemic heart disease and peripheral vascular disease. His family were also concerned that he was developing dementia, although he had declined to be referred for assessment of this issue. The specific issue of whether Mr Pope had capacity to make this and other health decisions was not the focus of the inquest and was not clearly elucidated. His General Practitioners did not attend as witnesses and I decided to proceed without adjournment. Mr Pope was admitted to The Whittington Hospital several times in 2013. During the first admission in February he was diagnosed with an abdominal aortic aneurysm, although abdominal pain did not form part of his presenting complaint. His general practitioner referred Mr Pope to a vascular surgeon for investigation of his aneurysm. Mr Pope’s next admission, from June to July 2013, was for abdominal pain. He was found to have ischaemic colitis, which settled with conservative treatment. He was discharged with plans for outpatient followup with general surgeons, vascular surgeons and cardiologists, in order to treat this condition on an elective basis. Mr Pope did not attend any of the outpatient appointments which were organised for him. His family gave evidence that Mr Pope would open letters addressed to himself (such as hospital correspondence) and not take any action. They felt that his developing dementia meant that he did not have the capacity to make this kind of decision relating to his health. As such, the family believed that they should have been informed of the dates of upcoming appointments, in order to ensure that Mr Pope attended. From the evidence 1 heard at the inquest, this does not seem to have happened. It is clear that Mr Pope’s general practitioner was informed when he did not attend appointments, which resulted in further referrals being made. On 6 December 2013 Mr Pope was readmitted to The Whittington Hospital with a further episode of ischaemic colitis. After an initial period during which this condition did not to warrant emergency treatment, he rapidly deteriorated on 11 December and was taken to the operating theatre. Unfortunately too much of the bowel was ischaemic for an operation to proceed. He died on 12 December. 5 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. – (1) Mr Pope’s family had concerns, which I share, that where a patient does not have capacity to make decisions about attending followup consultations, appointments might be missed when family members are not copied into correspondence. It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in the patient’s best interests to use this approach, to ensure followup occurs. It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision. Concerns were raised that there is no ‘backup’ process in place and that future deaths could occur as a consequence. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the addressees, 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 3 July 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following: (a) The Pope family, (b) The Care Quality Commission 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. 2 9 08 May 2014 Assistant Coroner R Brittain 3
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.
Whittington Health INHS| Executive Offices Magdala Avenue Ni9 SNF 26" June 2014 Tel: Fax Dr R Brittain Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Dr Brittain | am writing to respond to your Prevention of Future Deaths report dated 8 June 2014. We regret and acknowledge Mr Pope’s family’s and your concer. We have reviewed our processes, investigated what occurred in Mr Pope’s case, and considered if any actions are required to prevent an occurrence of this nature in future. You raised the following concern: "...where a patient does not have capacity to make decisions about attending follow-up consultations, appointments might be missed when family members are not copied into correspondence. It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in the patient's best interests to use this approach, to ensure follow up occurs. It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision. Concerns were raised that there is no ‘backup’ Process in place and that future deaths could occur as a consequence.” | summarise below, for completeness, our process for outpatient appointments and describe the safety net within this Process for patients who lack capacity. On referral to the Trust for an out-patient appointment, the GP/original referrer must send a completed referral letter, which should include all appropriate information according to the Referral Minimum Dataset (MDS). As part of the MDS the referrer must include any other supporting information e.g. disability, mental health issues, child protection issues, which indicate that the patient may be vulnerable and/or require additional support. (Ref. Whittington Health Elective Access Policy, Section 10.1). UCL UCLPartners W = Academic Health Selence Partnership Established as The Whittington Hospital NHS Trust When a referral is received, the patient is telephoned by a member of the Access Team to agree an appointment date and time. They are given the opportunity to accept, decline or to rearrange, the appointment. They are reminded of their out- patient appointment date and time via telephone 7 days before their appointment. They are given the opportunity to accept, decline and rearrange, or decline the appointment. Three days prior to their appointment patients receive a reminder text on their mobile phones or by telephone, if we do not have their mobile number. When patients do not attend (DNA) their out-patient appointment, the clinician in charge of the patient's care will decide if a further appointment is appropriate. The Trust Access Policy states that when patients do not attend their out-patient appointment they are discharged back to the care of their GP. (Ref. Whittington Health Elective Access Policy, Section 11.3) A letter is sent to the patient and their GP to inform the GP of the patient’s non attendance, which was the case with Mr Pope when he missed his out-patient appointments. if the GP is concerned that the patient should be seen in their clinic, they can request a further appointment and the Booking Team in the Patient Access Centre will re-book the appointment. if a patient is deemed not to have capacity, and a formal letter or email request from the GP, family member/representative or clinician is made to the Patient Access Centre, an alert will be raised prompting the staff to copy appointment letters for that patient to family members, GP or the appointed representative. The Patient Access Supervisor will place the alert on the Trust’s Patient Administration System, which flags this request each time a member of staff makes an appointment. The system will show the name and address of the person to whom the copies should be sent. Unfortunately in Mr Pope’s case, such an alert was not requested and therefore his out-patient appointment letters were not copied to anyone. Had such a request been received for Mr Pope, we would have been accommodated it, as described. To conclude, | hope you are assured that the Trust has appropriate and robust processes in place with respect to patients who lack capacity to make decisions to attend their out-patient appointments. Having considered your recommendation, we do not feel that out processes or the Elective Access Policy require any changes; however we do feel it would be helpful to send a communication to all the GPs in our area reminding them of our safety net processes for patients who lack capacity to attend appointments. Action: The Trust will send a communication to all GPs via the GP Bulletin to remind them to include any information with regard to vulnerable patients or patients who lack capacity in their referring letter; and to remind them of the option to request that out- patient appointment letters are copied to them or a nominated patient representative for patients who lack capacity to attend appointments. Yours sincer. Simon Pleydell Chief Executive
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