Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0221, written 19 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 | 19 May 2014 |
|---|---|
| Reference | 2014-0221 |
| Deceased | Gregg O’Reilly |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: Prevention of Future Deaths report
Gregg O’REILLY (died 21.01.14)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
Barts Health
Royal London Hospital
Whitechapel Road
London E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 04.02.14 I commenced an investigation into the death of Gregg
O’Reilly, aged 53. The investigation concluded at the end of the inquest
on 15.05.14.
I concluded that Mr O’Reilly died from two naturally occurring diseases,
contributed to by the recognised complications of medical treatment for
one of these.
His medical cause of death was:
1a bronchopneumonia and urinary tract infection
1b diverticular disease (treated) and cirrhosis of the liver
2 hypertensive heart disease.
1
4
CIRCUMSTANCES OF THE DEATH
Mr O’Reilly was admitted as an emergency to the Royal London Hospital
on 31.12.13. He was dehydrated and in a poor nutritional state, with a
high stoma output from his ileostomy, an acute kidney injury and a high
white cell count.
On 17.01.13, he deteriorated and went into multi organ failure. He then
suffered a bleed from his abdominal wound. The following day, he
suffered a further bleed and this had to be treated surgically, after which
he was admitted to critical care. However, he did not recover, and died
three days later.
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.
I heard that an opportunity was missed by the medical, ward nursing and
critical care nursing outreach teams, to refer Mr O’Reilly to critical care,
certainly by 17.01.14. It is unclear whether that would have changed the
outcome for him, but it meant that he was not offered optimal care. Given
the number of staff who could have made such a referral, it seems that
this issue goes further than individual error or lack of understanding. I
appreciate that also makes it a big issue to tackle.
Further, although he was on two hourly observations, no record of any
observation could be found between midnight on 17.01.14 and 3am on
18.01.14, when Mr O’Reilly was found to have suffered a second bleed
with very low blood pressure, and a cardiac arrest call was made.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that and your trust 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 15.07.14. I, the coroner, may extend the period.
2
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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
wife of Gregg O’Reilly
intensivist, Royal London Hospital
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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
19.01.14
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.
Barts Health NHS Trust Trust Executive Offices Barts Health NHS Trust Ground Floor, Pathology and Pharmacy Building Ref: SR756 8 July 2014 The Royal London Hospital 80 Newark Street Coroner ME Hassell London Senior Coroner Inner North London E1 2ES St Pancras Coroner's Court Main swi Camley Street London www.bartshealth.nhs.uk N1C 4PP By special delivery Dear Madam Inquest Touching the Death of Gregg O’Reilly | write in response to your Regulation 28: Report to Prevent Future Deaths received on 20 May 2014. | can inform you that investigation into your concerns regarding the opportunity missed by medical, ward nursing and critical care outreach teams, to refer Mr O’Reilly to critical care, as well as the absence of a record of observations between midnight and on 17 January 2014 and 0300 hours on 18 January 2014, when he was on two hourly observations, and was found to have suffered a second bleed with very low blood pressure, for which a cardiac arrest call was made, has now been concluded. | am satisfied that this investigation has been sufficiently robust, in that we have scrutinised all relevant records and interviewed staff to inform our investigation. | write to apprise you of the conclusions to the investigation. During the investigation, senior medical and nursing staff have investigated the concerns raised in your report as well as the wider issues which impacted upon Mr O'Reilly's death. The key recommendations of the investigation are set out below. 1. The Trust Executive Team to consider the wider learning points from this review and instigate changes as appropriate. 2. The relevant ward to have a Band 7 Sister recruited as a matter of urgency given the overall acuity of this ward and the need for senior leadership locally. 3. Ensure the transition period from a paper based system to the full electronic patient record is as short as possible and ensure the risks of the hybrid system are on the Risk Register and appropriate mitigation is in place. at Nigy, Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, F “ / igs The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross University Hospital. * a 5 a Asay Barts Health NHS Trust Explore the usage of an electronic patient record red flag to identify chronically ill patients who have complex care needs and require frequent admissions to hospital. This would involve the key contacts from the multi-professional teams being incorporated into this system to expedite care and ensure continuity for the patient and the family. 5. The Critical Care Outreach Team (CCOT) and the consultant intensivists to develop formal guidelines, outlining when CCOT should request a critical care medical review. 6. Chronically sick patients who are causing concern should have a “Case Review Meeting” which should involve all relevant teams involved in the care to agree and implement the overall management plan. 7. Managing the Acutely Ill Patient Group (MAIPG) to be revamped, by expanding the membership, ensuring greater participation of senior clinicians from all Clinical Academic Groups, setting clear objectives with timelines, to address the most important issues. This group has forged strategic links with the Trust Quality Group and the new Mortality Review Board to ensure greater executive awareness and support. Strengthening the links between MAIPG and the Care Quality Collaborative — Deteriorating Patient Group. 8. In line with the Berwick Report 2013 the MAIPG to have a patient or public representative to sit on the forum to voice concerns and challenge decision making to improve patient safety. 9. Ensure each clinical team conducts a Morbidity and Mortality review, ideally using an agreed Trust proforma for all patients who die in hospital. Any suspected preventable death identified to be escalated to the Mortality Group and a Serious Incident proforma raised. 10. Launch an Education Strategy to ensure all staff can identify a sick and deteriorating patient and can escalate concerns. The Trust medical and nursing Induction Programmes to incorporate a briefing on ‘Recognising and Responding to the Deteriorating Patient.’ 11. The Trust is planning an “all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations. 12. The Trust to re-establish the Critical Care Board, as a matter of urgency. The Terms of Reference, membership and Chair have now been agreed and a provisional date set of August 2014 has been set for the first meeting. st Moy, Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, F V/s The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital. A 7SAB\S Barts Health INHS| NHS Trust We have taken this as an opportunity to review our processes to enhance future care. The outcome of the investigation will be shared with all relevant Trust medical and nursing staff to ensure that these changes are put into practice. The effectiveness of the changes will be subject to regular audit. Thank you kindly for bringing your concerns to my attention. | trust you are assured | have taken them seriously and investigated them appropriately. Yours faithfully Medical Director Barts Health NHS Trust st Mou, Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, 3 Ves ExV (Vf: The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital. de *SAB©
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