Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0249, written 2 Jun 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 Jun 2014 |
|---|---|
| Reference | 2014-0249 |
| Deceased | Aimee Varney |
| Coroner | Tom Osborne |
| Coroner area | Bedfordshire & Luton |
| 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: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
THIS REPORT is being sent to:
Ms Pauline PHILIP
Chief Executive
L & D University Hospital
Lewsey Road
Luton
LU4 4DZ
1
CORONER
I am Mr Tom OSBORNE, Senior Coroner for the Coroner Area of
Bedfordshire and Luton.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5
3
INVESTIGATION and INQUEST
On the 19th June 2013 I commenced an Investigation into the death of
Aimee Sarah VARNEY aged 21 years. The Investigation concluded at the
end of the Inquest on 19th May 2014. The Conclusion of the Inquest was
that between January 2012 and April 2013 the deceased was undergoing
investigation for epilepsy at the Luton & Dunstable Hospital. She died
following a seizure on 16th June 2014 at her home address
Dunstable, Bedfordshire. The medical cause of death being:
I (a) Sudden Unexpected Death in Epilepsy
4
CIRCUMSTANCES OF THE DEATH
Aimee Sarah VARNEY had undergone investigations for epilepsy
between January 2012 and April 2013. She was seen at the Luton &
Dunstable Hospital on 22nd April 2013 following which a referral was
made for her to be seen by a Specialist at the Royal Free Hospital in
London.
The failure to refer her urgently, or at all, to a Specialised Unit resulted in
a lost opportunity to diagnose and further treat her condition. She died
following a seizure from Sudden Unexpected Death in Epilepsy on 16th
June 2013 at 22 Priory Heights, Dunstable, Bedfordshire.
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. That the NICE Guidelines for referring a patient with suspected
epilepsy to a Specialist Tertiary Centre were not followed.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe you, as the Chief Executive of the Luton & Dunstable University
Hospital, 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 28th 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 Interested Person(s):
The family
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 find
representations to me, the Coroner, at the time of your response, about
the release or the publication of your response by the Chief Coroner.
it useful or of
9
Dated this 2nd day of June 2014
……………………………………
Tom OSBORNE
Senior Coroner
Bedfordshire & Luton
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.
DUNSTABLE Our ref: PMP/ams 28 July 2014 Mr P Smith email: Coroner's Officer Direct tel HM Coroner's Office The Court House Woburn Street Ampthill Bedfordshire MK45 2HX By ona: es Dear Mr Smith Inquest touching the death of Aimee Sarah VARNEY Inquest held on 19" May 2014 at Coroner’s Court, Ampthill Thank you for your Regulation 28 Report, dated 2"? June 2014, in response to the death of Aimee Varney. The Trust has considered the following matter of concern: 1) That the NICE (National Institute for Health and Care Excellence) Guidelines for referring a patient with suspected epilepsy to a specialist tertiary centre were not followed. The Medical Director is responsible for ensuring every new NICE guideline is allocated to the relevant speciality. The appropriate Clinical Audit and Effectiveness Committee (CAEC) Lead, the Finance and the Clinical Director all receive copies for discussion and dissemination. As for all NHS bodies there are occasions where the hospital cannot immediately comply with NICE guidance. This can be due to resources and requires negotiation with our commissioners to fund, for example, high value new drug therapies. The allocations are recorded on a central database managed by the Clinical Quality Department. They also record whether the relevant speciality has declared the guideline to be non-applicable, applicable and implemented or applicable but the Trust is non-compliant. A Risk Register is kept of all guidelines the Trust is not able to immediately comply with; this is regularly monitored to ensure the relevant changes are made as soon as possible. individual Clinicians have ready access to the relevant NICE guidelines via the Hospital's Intranet. They can also gain access via the NICE website www.nice.org.uk/guidance Luton and Dunstable University Hospital NHS | Bea Fruncet ne Taagt However it must be emphasised that they are guidelines, not tramlines that the treating clinician must rigidly follow. NICE state “...health and social care professionals are actively encouraged to follow our recommendations to help them deliver the highest quality care. Of course, our recommendations are not intended to replace the professional expertise and clinical judgement of health professionals, as they discuss treatment options with their patients.” There will be individual patients where the treating clinician uses their own judgement and does not follow the absolute guidance. In this particular case the expert report was prepared by a clinician with a special interest in epilepsy, from a specialist tertiary centre. Their report may not reflect what is considered acceptable practice by a general neurologist, with a general neurology practice, that is managing a patient with epilepsy. For this reason we are commissioning a further report, from an independent general neurologist, to get assurance that the individual clinician’s practice did not fall outside the threshold of reasonable practice. | hope you are reassured that the Trust has appropriate systems for the logging and disseminating of NICE Guidelines. Yours sincerely Pauline Philip Chief Executive Officer
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