Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0355, written 1 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2014 |
|---|---|
| Reference | 2014-0355 |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. 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. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 41. Public Enquiries Unit Department of Health Richmond House 79 Whitehall London SW1A 2NS 2. The British Thoracic Society 17 Doughty Street London WC1N 2PL 3. The Royal College of Anaesthetists Churchill House 35 Red Lion Square London WC1R 4SG 4. College of Emergency Medicine 7-9 Bream’s Building London EC4A 1DT CORONER | [am M. E. Voisin, Senior Coroner, for the Area of Avon CORONER'S LEGAL POWERS | 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, wl INVESTIGATION and INQUEST On 24th April 2014 | commenced an investigation into the death of Gerald Trevor WERRETT, aged 67. The investigation concluded at the end of the inquest on 25th July 2014. The conclusion of the inquest was that Mr Werrett died due to: la Bilateral bronchopneumonia Ib Chronic obstructive airways disease I Ischaemic heart disease His death was contributed to by a misplaced chest drain and the conclusion given was natural causes contributed to by neglect. CIRCUMSTANCES OF THE DEATH Mr. Werrett was admitted to hospital on 28" February 2014 with infective exacerbation of his chronic obstructive airways disease together with a number of co-morbidities. During his admission he required a number of chest drains to be inserted to treat his condition. On 31% March 2014 he required a further drain to be inserted and two chest x-rays were taken, It was clear from the evidence and indeed not disputed that the chest x-rays were inverted and mislabelled which resulted in the registrar misinterpreting the one x-ray that she looked at (she did not look at both), this resulted in a chest drain being put in the left side when in fact the pneumothorax was on the right. Mr. Werrett subsequently required achest drain to be inserted on the right as well. Mr. Werrett’s treating consultant gave evidence and said that the chest drain was wrongly inserted, having two chest drains caused pain and made him less mobile with cough difficulties, the staff clearly tried desperately to rectify the situation but that the second unnecessary drain had an impact and a contributory factor to his death. The incident on 31 March 2014 resulted in a never event and the Trust have now rolled out a safety check list to be completed prior to the insertion of a chest drain together with guidelines for the insertion of chest drains. 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. - Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: A lead anatomical marker was not used when taking the chest x-ray Both chest x-rays were incorrectly labelled, and this error was not identied by the clinician The chest x-ray that was looked at was misinterpreted Both chest x-rays were not considered. The cardiac silhouette was not interpreted correctly Mr. Werrett was not examined prior to the insertion of the chest drain. N= QaRw North Bristol NHS Trust have clearly learnt a valuable lesson following this incident and have devised a safety check list and guideline which could be of assistance to the wider medical community. North Bristol NHS Trust have indicated that they would be willing to share the check list and guideline which if implemented could avoid a similar event happening again. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 29" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — the Family of Mr. Werrett and North Bristol NHS Trust. 1am 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. +" August 2014 ME. ee
4 responses 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.
ee British Thoracic Society 17 Doughty Street, London WC1N 2PL T: +44 (0} 20 7831 8778 F: +44 (0) 20 7831 8766 bts@brit-thoracic.org.uk www.brit-thoracic.org.uk Registered as a charity in England and Wales No, 285174 Scottish Charity No. SC041209 Company Registration No, 1645201 Mrs M E Voisin Her Majesty’s Senior Coroner Area of Avon The Coroner’s Court The Courthouse Old Weston Road Flax Bourton BRISTOL BS48 1UL 3 September 2014 Dear Mrs Voison Gerald Trevor WERRETT Thank you for asking the British Thoracic Society to provide a report following the inquest on the above individual. tam a Consultant Physician and work at the University Hospital of North Staffordshire. | am replying on the basis that | am the Honorary Secretary of the British Thoracic Society and a Consultant Respiratory Physician for over 20 years. | note that the invitation for comment has been produced on a regulation 28 - to prevent future deaths. The inquest report | have seen states that the chest drain was wrongly inserted and this apparently contributed to the patient's death. While clearly having minimal details on which to comment, | note that the Trust has developed a safety check fist which they are willing to share with other parties. Regrettably, harm from chest drains is well recognised. The National Patient Safety Agency (NPSA) produced a Rapid Response Report and supporting information in May 2008. The latter give background information and refers very clearly to the Guideline which was developed by the British Thoracic Society in 2003. The Rapid Response report states clearly questions that the team should ask about before placement of chest drains. In 2010 the British Thoracic Society published an 82 page update on management of pleural disease which includes safe insertion of chest drains (Thorax 2010 (August) Vol. 65, supplement 2). This publication is freely available in most medical tibraries and, more importantly, is available on the British Thoracic Society website which is open to all individuals. It is one of the most frequently visited sections of the Society’s website. Recognising the problems that can occur with the placement of chest drains, in part mandated by the NPSA, many hospitals have already produced their own local guidelines, based upon those of the British Thoracic Society. | am unsure if such focal guidelines were available at the Trust where the event occurred and how well they were followed. The British Thoracic Society thanks you for the interest in our guidelines and notes that these are more comprehensive and recent than information available from the NPSA. With kind regards Yours sigcerely PC Consultant Physician Honorary Secre’ ritish Thoracic Society
iol From Rt Hon Norman Lamb MP Aor : Minister of State for Care and Support AES Department Department of Health of Health Richmond House 79 Whitehall London SW1A 2NS Mrs M Voisin HM Senior Coroner for Avon The Coroner's Court The Courthouse Old Weston Road Flax Bourton 29 SEP 2014 BS48 1UL Thank you for your letter to Jeremy Hunt about the death of Mr Werrett. | am saddened to hear of Mr Werrett’s death, and offer my sincere condolences to his family. Your report details the events prior to Mr Werrett’s death which included x-rays which were inverted and mislabelled, resulting in the drain being inserted on the wrong side of Mr Werrett’s body. This resulted in an additional drain, which was found to have been a contributory factor in his death. You listed a number of concerns about the insertion of these chest drains and the mistakes made in Mr Werret’s care. These have, | understand, been addressed by North Bristol NHS Trust. However, | have noted your suggestion that the safety check list and guideline that the Trust has implemented since Mr Werrett’s death might usefully be shared with other organisations in the NHS to prevent future deaths. The risks of inserting a chest drain on the wrong side are already to known to the NHS through patient safety incident reports received through the National Reporting and Learning System (NRLS). The NRLS is a database of patient safety incident reports submitted voluntarily by organisations across the NHS. Trusts regularly upload incident reports from their local systems to the NRLS specifically for purposes of learning. Data is interrogated by national patient safety experts to spot trends, specific incidents of concern, or emerging risks to patient safety. The WHO Surgical Safety Checklist was designed as a tool to improve the safety of surgery by reducing deaths and complications. The checklist specifically addresses : Department of Health issues relating to wrong site surgery which includes the insertion of drains, An NPSA Alert issued in 2009 recommended that the checklist should be adapted for local use. The alert can be found at http://www.nris.npsa.nhs.uk/resources/?entryid45=59860. NHS England (NHSE) has recently established a Reference Group to take forward the recommendation made by the Surgical Never Events Taskforce in February 2014. This Taskforce was commissioned to examine and clarify the reasons for the persistence of these patient safety incidents, and to produce a report making recommendations on how they can be eradicated http:/Awww.england.nhs.uk/ourwork/patientsafety/never-events/surgical/. One of the key recommendations in this report is to develop National Standards for Operating Department Practice that will support all providers of NHS-funded care to develop and maintain their own more detailed standardised local procedures. The scope of the standards will cover all surgical procedures and not just those being undertaken in the operating theatre environment. Current timescale for the development of the standards is early 2015. Once the standards have been developed the next phase of this work will be to address how the standards should be implemented and this will include requirements for educators, commissioners and regulators. If North Bristol Healthcare NHS Trust would share the checklist it has developed with NHS England there may be opportunity to include it as a resource for other Trusts to use or adapt when the standards are implemented. | hope that this information is helpful and | thank you for bringing the circumstances of Mr Werrett’s death to our attention. NORMAN LAMB =~ ned —
The College of Emergency Medicine Patron: HRH The Princess Royal 7-9 Breams Buildings Tel +44 (0}207 404 1999 London Fax +44 (0}207 067 1267 EC4A 1DT www.collemergencymed.ac.uk Mrs ME Voisin HM Senior Coroner The Coroner’s Court The Courthouse Old Western Road Flax Bourton Bristol BS48 1UL 16th September 2014 Dear Mrs Voisin, Regulation 28 Report — Gerald Trevor Werrett Thank you for alerting us to the case of Mr Werrett in your report received on 5"" August. The College shares your concerns, and will take the following actions: ¢ Highlight this case and the findings of the investigation in the next Safety Newsflash to its members. e Share North Bristol NHS Trust’s safety check list and guidelines on our website once received. Following this incident, the key things we feel that should be reviewed locally are whether the environment supports the review of X-rays (e.g. availability of IT in the room where the procedure was carried out), if the doctor was trained in the use of ultrasound guidance for insertion of chest drains and whether ultrasound was available, in addition to the availability of rapid 24 hour reporting. The College is dedicated to reducing the risk of ‘never events’ and promoting safety in the workplace, through guidance and regular safety news updates. Thanks again for bringing our attention to this issue. With kind regards Chair, Quality in Emergency Care Committee Excellence in Emergency Care incorporated by Royal Charter, 2008 ¢ Registered Charity number 1122689
Churchill House ey g The Royal College of Anaesthetists a5 ed ion Square Educating, Training and Setting Standards in Anaesthesia, London WC1R 4SG Critical Care and Pain Medicine tel:020 7092 1500 fax: 020 7092 1730 Chief Executive email: info@rcoa.ac.uk Kevin Storey web; www.rcoa.ac.uk Mrs ME Voisin Her Majesty’s Senior Coroner for the Area of Avon The Coroner’s Court The Courthouse Old Weston Road Flax Bourton BS48 1UL 29" August 2014 Ref: Gerald Trevor WERRETT Dear Mrs Voisin, Further to my letter of 11 August 2014, regarding the death of Mr G T Werrett and the Regulation 28 Report; I have now investigated training and education aspects of chest drain insertion for anaesthetists. Please note the following information together with a summary of appropriate actions taken or planned. Training and trainees — chest drain insertion is covered at several stages of the anaesthesia training curriculum. Initial insertion techniques are assessed at the basic level of training and management responsibilities for the procedure then progress through training, and across increasingly complex environments. Subsequent training and work-place based assessment advances to the longer term management of patients with chest drains and dealing with emergency patients and trauma situations. These areas of training are under annual review by our Training Committee and we will ensure particular attention is attached to correct site location at the next review. Further to general anaesthesia requirements for training in chest drain insertion, additional training and assessment takes place in several sub-specialty areas e.g. paediatrics, obstetrics and intensive care. This may take place in the advanced or higher levels of training and/or subsequent to gaining entry to the Specialist Register of the GMC and progressing into sub-specialty interest areas. Career grade education — for anaesthetists who are entered on the specialist register, or for those who opt-out of advanced training at the Specialty Doctor level, there is an ongoing need to maintain competence in all areas of clinical practice. This is a requirement of revalidation and necessary to maintain a licence to practice with the General Medical Council. This competence may be achieved by sub-specialty development, engagement on courses such as Advanced Life Support (ALS) or workplace experience coupled with attendance at events and conferences which are quality assessed and recognised for Continuous Professional Development (CPD) points by the College. Several past professional CPD events have been identified where the use of chest drains, particularly with the inclusion of chest ultrasound, has been covered. We can find no similar planned events in The RCoA: Advancing Patient Care and Promoting Safety Patron: HRH The Princess Royal REGISTERED CHARITY NO: 1013887 VAT REGISTRATION NO:GB 927 2364 18 REGISTERED CHARITY IN SCOTLAND NO:SC037737 our calendar for the immediate future; however, when this occurs we will highlight the need to emphasise further safe practice at insertion. In addition, we have also identified this is a frequent topic for events managed by colleagues at the Intensive Care Society and have highlighted to them a need to stress safe practice and double checking the correct site before insertion. Actions to highlight the issue to other providers of events earning anaesthesia CPD credit will be progressed through our safety network as below. General aspects - The College was alerted to a specific chest drain insertion problem earlier this year which led to notification to our safety network in March 2014. The initial notification and subsequent alert were completely anonymised; however, from the detail you have provided we now believe this was the same incident you now highlight and our ongoing work with colleagues will focus on lessons to be learned and shared from this situation. You would wish to be aware of an alert issued by the National Patient Safety Agency (NPSA) in May 2008 regarding chest drains (http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59887 ) and this is still a key point of reference for anaesthetists and others in their safe use. Despite the closure of the NPSA we believe the responsibility for these alerts continues through the safety department within NHS England and we have advised them of this death, with anonymised detail, and requested they review the alert and consider its re-issue. L have reminded each of the directors in the College, with responsibility for training and education, about the need to continue to stress the importance of correct chest drain insertion techniques at all stages of professional development and beyond this into continuing practice. As stated in my previous letter, I have also issued an alert to our network of senior anaesthetists, risk managers and clinical directors (approximately 800 healthcare staff across the UK) about the need to check local policy and procedures to ensure ongoing vigilance where chest drains are to be used. Finally, through our Safe Anaesthesia Liaison Group we will now ask for reports related to chest drain insertion incidents to be forwarded to us as soon as they occur so we may monitor any incidence of problems more closely and take remedial action where necessary. I hope this provides reassurance of the gravity we attach to this incident and the steps we are taking to learn from it to avoid recurrence. Yours sincerely, Deputy Chief Execufye and Director of Clinical Quality
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