Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0389, written 29 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 | 29 Aug 2014 |
|---|---|
| Reference | 2014-0389 |
| Deceased | Linda Lloyd |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospital 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: 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:
1. The Chief Executive,
Blackpool Teaching Hospital NHS Foundation Trust
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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 10th January 2014 an investigation commenced into the death of Linda Rose Lloyd
aged 63 years. The investigation concluded at the end of the inquest heard on 1st April
and 28th August 2014.
The record of the inquest confirmed as follows:
The Medical cause of death was
Ia Acute subdural haemorrhage
The conclusion of the Coroner as to the death was Narrative conclusion as follows:
Having complained of a headache earlier that morning, on 2nd January 2014 Linda
Rose Lloyd was found at her home address at 19:14 hours with a Glasgow coma
score of 10/15 and unable to verbally respond to ambulance personnel. She was
taken to hospital where she was triaged and assessed as being a very urgent
priority. She was not assessed by a doctor until 22:12 hours and noted to have a
Glasgow coma score of 7/15. A CT scan was undertaken at 01:15 hours the
following morning which confirmed the presence of an acute subdural
haemorrhage. She was not felt to be suitable for neurosurgical intervention and
was pronounced deceased at 19:55 hours on 3rd January 2014. There was a delay
in treatment which could have affected the outcome.
4
CIRCUMSTANCES OF THE DEATH
See the contents of section 3 above.
1
The inquest was informed that at the time of Mrs. Lloyd’s attendance at the hospital her
triage assessment was undertaken by a junior paediatric staff nurse, and that these
nurses were sometimes utilised to provide cover in the ambulance triage area when staff
shortages ensued. Further, that although Mrs. Lloyd was triaged correctly, that the
inexperience of the nurse meant that information that the patient was a very urgent
priority was not passed on to either the nursing staff for the relevant area or a senior
doctor and so was not acted upon as an emergency.
The inquest was told by an independent Consultant in Accident and Emergency
Medicine that given the patient was suffering from a time critical lesion any delays in
assessment, diagnosis and treatment must be regarded as contributory factors to a poor
outcome and that certain aspects of her care could and should have been addressed
more promptly in terms of:
Medical assessment within 10 minutes of triage;
Initial neurological observations including assessment of pupils and Glasgow
Coma Score, plus ongoing regular monitoring of her neurological state starting
with every 10 to 15 minutes;
A more immediate response to a history of warfarin use and findings of a raised
INR requiring treatment;
CT scanning of the head should have taken place as soon as possible after
arrival and certainly within one hour of arrival;
Earlier discussion with the Neurosurgical team.
The Consultant further informed the inquest that having triaged the patient and
designated her as a “very urgent” priority and then doing nothing about it was completely
unacceptable. He added that it is also unacceptable that it was over two hours before
Mrs. Lloyd had a second GCS score recorded by an examining doctor and that there
was then a further long delay before a GCS score was taken again and recorded on an
observation chart. Also, he felt there too long a delay in administering drugs to reverse
the effect of warfarin therapy in someone who was actively bleeding.
He concluded that it is vital that the Trust undertake a review of this case to address
these areas to ensure that any future patients with time critical neurosurgical lesions
have prompt assessment, investigation, referral and transfer to optimise the potential for
a better 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. –
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
During the Inquiry, I received written evidence a review has taken place further
to this incident, and that it is now only the very senior paediatric nurses who are
able to triage and that a triage training plan has been implemented which is to
be completed by all nurses who triage and is designed to ensure all triage staff
are able to assess and direct initial care for patients and ensure they are placed
in the most appropriate area post triage.
I was further informed that changes made to departmental policy have
incorporated the necessity to consider the effects of patients treated with
warfarin, and that A & E consultants are working to improve and implement an
2
However, having concluded this inquest, I now write to the Trust to confirm that in my
view the Trust should take action because:
Although encouraged by the steps being taken, I remain concerned that the procedures
in place at the hospital are insufficiently robust, and that staffing levels do not provide
the Trust with sufficient resilience, to enable the Trust to minimise the risks of further
deaths in similar circumstances particularly given the criticisms made by the
independent expert and the number of areas of concern he raises.
I would therefore be obliged if the Trust would write to me in due course to confirm what
steps if any the Trust proposes to take to address these areas of concern.
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 24th October 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
The family of Linda Rose Lloyd
The Coroners Society
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
A.A.Wilson
Alan Wilson
Senior Coroner for the area of Blackpool & Fylde
Dated: 29th August 2014
3
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