Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0388, written 1 Sep 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 Sep 2014 |
|---|---|
| Reference | 2014-0388 |
| Deceased | Thomas Taylor |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Free London NHS Foundation Trust |
| 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.
Regulation 28: Prevention of Future Deaths report
Thomas Charles TAYLOR (died 13.03.14)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
Royal Free London NHS Trust
Royal Free Hospital
Pond Street
London NW3 2QG
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 27 March 2014 I commenced an investigation into the death of
Thomas Charles Taylor, aged 54 years. The investigation concluded at
the end of the inquest earlier today. I made a narrative determination,
which I attach to this letter.
4
CIRCUMSTANCES OF THE DEATH
Mr Taylor was a diabetic who died in the Royal Free Hospital after a
delay in the administration of insulin, following the loss of medical notes
and drug chart.
1
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 contained within the narrative
attached, but in brief -
1. The ward where Mr Taylor was being nursed seemed rudderless,
operating without clarity of leadership or support.
On 21 February, a bank nurse worked alone in the morning,
though was joined by another agency nurse at lunch time, with
only a senior nurse in the office.
On 22 February, the nurse in charge appeared unclear that he had
any additional responsibility by virtue of being the nurse in charge,
other than to allocate nurses to patients.
Despite only three nurses being on duty on 22 February, the nurse
in charge took a break at the same time as another nurse.
There was a conflict of views among the nurses that day about
who had primary care of Mr Taylor.
2. There was no protocol for the loss of notes and drug chart.
Attempts by the ward staff to locate these were not prompt,
focused or sustained. The notes and chart were later found simply
in a drawer on the ward.
3. When Mr Taylor refused to have his blood sugar checked, there
seemed no well understood protocol for re-checking or escalation.
Immediate provision was not made for the administration of insulin,
and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd,
after the administration of the delayed dose of insulin his nurses
did not immediately re-check his blood sugar, perform neurological
observations or alert medical staff.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 3 November 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Professor Dame Sally Davies, Chief Medical Officer for England
, daughters of Thomas Taylor
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
interest. You may make
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
01.09.14
3
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