Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0258, written 9 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 | 9 Jun 2014 |
|---|---|
| Reference | 2014-0258 |
| Deceased | William Beckwith |
| Coroner | Robert Hunter |
| Coroner area | Derby & Derbyshire |
| 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.
OFFICE OF HER MAJESTY’S CORONER
DERBY& DERBYSHIRE CORONER’S AREA
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive Chesterfield Royal Hospital
1
CORONER
I am Robert W Hunter, senior coroner, for the coroner area of Derby and Derbyshire.
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
On18th October 2013 I commenced an investigation into the death of William Leonard
Beckwith, 91 years old. The investigation concluded at the end of the inquest on 10th
April 2014. The conclusion of the inquest was one of Accidental Death.
The medical Cause of Death being:
1a. Gastro-intestinal tract haemorrhage.
1b. Duodenal Ulcer
II. Cervical spine fracture (treated), Acute stress ulceration, Bronchopneumonia
4
CIRCUMSTANCES OF THE DEATH
On the 13th September 2013 William Leonard Beckwith sustained a fracture to his
cervical spine resulting from a fall at home. He attended the accident and
emergency department of the Chesterfield Royal Hospital. Medical and Nursing
staff were aware of a history of previous falls. Reduced range of movement of his
cervical spine was noted at that time, however his fracture was not diagnosed and
he was discharged home at 04:17 hours in the morning. He was readmitted with
acute stridor on the 15th September 2013 caused by a blood clot from the cervical
fracture compressing his wind pipe. Despite management in intensive care and on
the ward he continued to deteriorate and died on the 11th October 2013. From the
evidence heard at inquest, on the balance of probabilities, earlier diagnosis of the
fracture would not have affected the outcome.
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. –
A 91 year old patient, with a history of falls and who had attended A&E due to a fall was
discharged home at 04:17 hours in the early morning to his elderly wife. There was no
formal assessment as to his abilities, the home environment or his wife’s abilities to look
after him. No consideration was given to post discharge planning or assessment of
needs such as district nurse or social care follow up. The Department, at that time, did
not have in place any formal policy or procedure for risk assessing the safety of
discharging a frail, elderly patient to home in the early hours of the morning.
6
ACTION SHOULD BE TAKEN
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Monday 4th August 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
Persons
Mr Beckwith’s son.
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.
9
9th June 2014
Dr Robert W Hunter
Senior 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.
29 UL 2 | Chesterfield Royal Hospital een Lawn | NHS5 Foundation Trust ~ Calow Chesterfield $44 5BL Tek 01246 277271 Minicom: 01246 512611 awww. chesterfieldroyal NAs.uk Direct Line: 01246 512144 Fax Number: 01246 512737 E Mail Your ref: Our ref: 23rd July 2014 PRIVATE AND CONFIDENTIAL Dr Hunter H. M. Coroner 5-6 Royal Court Basil Close Chesterfield Derbyshire Dear Dr Hunter Re: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of William Leonard Beckwith Further to my letter dated 13" June 201, | am now in a position to offer you our substantive response to the concerns you raised in your Regulation 28 report relating to the above gentleman. There has been guidance for staff within the Emergency Department since 2012 in relation to the assessment of elderly patients presenting to the department following a fall. The guidance in the form of a flow chart was intended to assist staff in conjunction with their clinical assessment to determine whether or not the patient required admission or could be discharged. However, in light of your letter a multidisciplinary review of this document is currently in progress with in put from senior nursing staff, and care of the elderly physicians within the Medicine & Emergency Care Division. The result of this review will be a clear policy for staff to follow which | expect to be finalised by the end of August. Once the policy has been ratified, | will provide you with a copy for your information. | hope that you can see that we have taken your recommendations very seriously, but if you have any further concerns or queries in relation to this matter please do not hesitate to contact me. Yours sincerely Gavin Boyle 7, Chief Executive /
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