Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0316, written 9 Jul 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 Jul 2014 |
|---|---|
| Reference | 2014-0316 |
| Deceased | Thomas Smith |
| Coroner | Christopher Woolley |
| Coroner area | Cardiff & the Vale of Glamorgan |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Clinical Director, Cwm Taf Board, Out of Hours service
2. The National Institute for Health and Clinical excellence
3. The Chief Executive Prince Charles Hospital, Merthyr Tydfil
4. The Senior Manager for Investigations and Quality Improvement for Cwm
Taf University Health Board
1
CORONER
I am Christopher John Woolley, Assistant Coroner, for the Coroner area of Cardiff and
the Vale of Glamorgan
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
On 5th June 2013 I commenced an investigation into the death of Thomas George Smith
aged 13. The investigation concluded at the end of the inquest on 30th June 2014. The
medical cause of death was: 1A Pneumococcus meningitis. I returned a conclusion of
Natural Causes.
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CIRCUMSTANCES OF THE DEATH
Thomas had been seen by the Out of Hours doctor at 13.09 hours on 27th May 2014
after a two to three day history of headache, neck pain and vomiting. The doctor had
checked for signs of meningitis and made a diagnosis of “headache - ? cause”. The out
of hours doctor decided to admit him to hospital. Thomas was admitted to Prince
Charles Hospital on 27th May 2013 at 14.00 hours. He was seen by a doctor there
at 14.30. After speaking to the consultant after intervention from the nursing
staff he decided to perform hourly observations. He noted signs of raised intracranial
pressure. Thomas remained conscious and alert. At 15.00 hours the neurological
observations were within normal limits. At 16.00 hours his blood pressure had risen and
he was pyrexial. The nursing staff were concerned about raised intracranial pressure
. He examined Thomas and thought there were two or three factors
and alerted
that would be consistent with meningitis but that he did not have other factors. At 16.20
he was seen by
who concluded that the illness was infective in origin. An IV
cannula was inserted but no antibiotics were given. At 16.30 hours he was still pyrexial.
The consultant Dr Afifi attempted to examine Thomas at 16.40 hours but decided to wait
until blood tests were done. At 17.00 hours Thomas diastolic blood pressure had risen to
95. The nursing staff had continuing concerns. At 18.00 hours Thomas was still alert and
talking. At 18.30 hours
likely had meningitis. He prescribed ceftriaxone. Up until this point no medication had
been prescribed for Thomas, and no measures had been taken to reduce his intracranial
pressure. At 18.35 hours Thomas became unresponsive and cyanosed. It is probable
that he had suffered a brain herniation. The crash team was called at 18.40 hours but
examined Thomas and concluded that Thomas most
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Thomas did not improve and died on the 29th May at 18.45 hours.
CORONER’S CONCERNS
5
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. –
For the Clinical Director, Cwm Taf Board, Out of Hours service
(1) No criticism is made of the actions of the Out of Hours Doctor
.
The inquest however revealed the importance of full and accurate handover
between primary and secondary care providers. Such handovers should record
full observations and details of any medication already given (for instance
painkillers may mask fever). Can the clinical director confirm OOH doctors
observe this practice.
(2) The Coroner noted that it was only by chance that Thomas was seen more
quickly than usual (because the case was “modified” and removed from the
pool). Given the greater susceptibility of children to deteriorate in health the
Coroner would like to see children’s cases be given a greater “weighting” so that
they can be seen more quickly than adult cases if these can safely be delayed.
(3) The Coroner would ask that the OOH service notes the concern expressed
below that Thomas should have been transferred to hospital by ambulance.
For the National Institute for Health and Clinical excellence
(1) The Coroner notes the guidance at page 61 of the June 2010 publication
“Bacterial meningitis and meningococcal septicaemia” to the effect that “the
available evidence does not allow any conclusion to be drawn about whether or
not pre-hospital parenteral antibiotics affect mortality or morbidity”. This is
however contradicted by the evidence heard at inquest from eminent experts
who gave their empirical conclusions
that the literature suggested that antibiotics should be given sooner rather than
later in cases of meningitis. In the event of primary care doctors being involved
in a remote location there might be a delay of some hours before transfer to
secondary care. The Coroner also noted the Guidelines issued by the Scientific
Advisory Committee of HPSC (Eire) which recommended that primary care
providers administer antibiotics in cases of suspected meningitis (at page 17)
“all GPs and advanced paramedics should have benzylpenicillin available when
attending patients and should be ready to administer it without delay to patients
with a systemic febrile illness and a petechial or purpuric rash”. The Coroner
would recommend that the existing guidance is revisited.
For The Chief Executive Prince Charles Hospital, Merthyr Tydfil
(1) The inquest revealed the importance of observing physiological trends in the
patient’s condition, rather than observing readings on a “snap shot” basis. The
Coroner considers that comprehensive time series data would have provided
clinicians with a sounder platform for assessing Thomas. Can the Chief
Executive confirm that this will be the practice at PCH?
(2) The inquest revealed a somewhat fragmented approach to patient care, with
nursing staff concerns not being acted on promptly by doctors. One expert
highlighted the importance of a “whole team approach” where information could
be freely shared and acted upon by nursing staff professionals. The Coroner
suggests that this should be the correct approach. The Coroner noted with
concern that at PCH nursing colleagues are not involved in a team debrief. The
Coroner considers that they always should be involved.
(3) Similarly the expert commented that there appeared to be a reluctance on the
paediatric ward to bring in other disciplines from the hospital where this might be
2
(4) It appeared at the inquest as if the clinicians had adopted an “exclusionary
focus” to rule out meningitis rather than an “inclusionary focus” so as to be able
to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner
considers that the inclusionary approach is appropriate where a patient presents
with some of the signs of meningitis. It should be standard practice at PCH for
raised Intracranial pressure to be treated without delay even if a diagnosis is
awaited on the underlying condition.
(5) The expert raised the possibility of having a paediatric ITU. It is appreciated that
PCH may not have the resources to have such a facility itself but the Coroner
would like to see consideration given to this within the Board and between
neighbouring Health Boards.
(6) There was a divergence of evidence at the hearing between
and
while
– with the former suggesting that at one point in the afternoon that he could not
find
said he had been in his office all the time. While the
resolution of this conflict was not necessary for the purposes of the inquest it
does reveal a situation where (for whatever reason) a registrar was not able to
obtain the advice of the consultant when he needed it. It appeared to the
Coroner to be archaic for the Registrar to have to physically go looking for the
Consultant on the ward – there must be modern telecommunication means to
ensure that the consultant is always available for advice even if remotely.
For the Senior Manager for Investigations and Quality Improvement for Cwm Taf
University Health Board
(1) The Senior Manager is asked to note and comment on all the items above which
fall within the control of Cwm Taf Health Board. The Coroner notes and
approves the work that has already taken place (as shown in the letter dated
25th June 2014) but considers that further work needs to be done as suggested
by the actions above. The Coroner asks that the Senior Manager takes a
leading role in coordinating the response within the Board.
(2) One of the experts recommended that a task force be commissioned within
Cwm Taf to improve communication between primary and secondary care
services. The Coroner agrees and recommends this. The Coroner has
emphasised above the importance of the handover from primary carer to assist
the secondary care provider (e.g. by highlighting red flag signals). Similarly the
Coroner has recommended that other specialists be brought in where they have
expertise not shared by paediatric colleagues and expects the Senior Manager
to endorse this approach.
(3) In this case Thomas was transferred to hospital by his mother. Although he
suffered no ill effects from this the experts agreed that such a transfer should
have been undertaken by ambulance. The Coroner suggests this should be the
standard approach.
(4) The expert recommends a “stress testing of ward management” through a
clinical scenario simulation of emergencies within ward areas. This could also
test how to improve communication during times of evolving emergencies.
Given the difficulties in internal communication as revealed by this inquest the
Coroner suggests this would be a valuable exercise.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that (1) The
Clinical Director, Cwm Taf Board, Out of Hours Service, (2) The National Institute for
Health and Clinical Excellence, (3) Prince Charles Hospital, Merthyr Tydfil and (4) The
Senior Manager for Investigations and Quality Improvement for Cwm Taf University
Health Board have the power to take such action.
3
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 9th September 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 1.
(Thomas’ parents)
I have also sent it to the following persons:
Chief Medical Examiner for University Hospital of Wales
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 July 2014
C J Woolley Assistant Coroner, Cardiff and the Vale of Glamorgan
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