Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0408, written 18 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 | 18 Sep 2014 |
|---|---|
| Reference | 2014-0408 |
| Deceased | Janet Goodacre |
| Coroner | Lydia Brown |
| Coroner area | Leicester City & South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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. Mr John Adler, Chief Executive, University Hospitals of Leicester NHS Trust 1 CORONER I am Lydia Brown assistant coroner, for the coroner area of Leicester (City and South) 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 24 May 2013 I commenced an investigation into the death of Janet Doreen Goodacre, age 88. The investigation concluded at the end of the inquest on 10th September 2014. The cause of death was: 1a Acute Gastrointestinal bleed, 1b. Combination of antiplatelet and anticoagulation therapy, 1c. Atrial Fibrillation and acute coronary syndrome, 2. Myocardial infarction: Congestive cardiac failure. The conclusion of the inquest was a narrative conclusion : Mrs Goodacre was admitted to Leicester Royal Infirmary on 1st May 2013 and she remained an in-patient until her death on 21st May 2013. During her stay she developed atrial fibrillation and was started on warfarin, and continued on other medications including deltaparin and aspirin. On the balance of probabilities this combination of medication provoked and then exacerbated a gastro intestinal bleed which led to her death. This was a recognised complication of her necessary medical treatment. CIRCUMSTANCES OF THE DEATH See Narrative Conclusion above 4 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. – University Hospitals of Leicester NHS Trust (“the Trust”) prepared an Investigation report concerning this death, and this was signed off on 15th January 2014. A copy was duly provided to the Coroner’s office in accordance with the local approved information sharing agreement. On the day of the inquest itself, nearly 9 months later, without any amendments or further communications from the Trust, Evidence was heard that (1) the Trust acknowledged that the report was factually incorrect 1 (2) That the only 2 “Root causes” identified in the report were incorrect (3) the Clinical Lead (who signed off the Investigation Report) said it was “flawed” and “not helpful” I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors. I request to be advised of any actions that have been taken to improve and oversee the preparation and conclusions of Investigation Reports, and that consideration be given to introduce a system to re-open any reports found to be inadequate or erroneous. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 6th 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 Chief Coroner and to the following Interested Persons: (Daughter Of Mrs Goodacre ) I have also sent it to it useful or of interest. Medical Director NHS England who may find 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 18 September 2014 2
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.
University Hospitals of Leicester r.!1:bj
NHS Trust
,
Chief Executive
Mrs Catherine Mason ,
Her Majesty's Coroner,
Leicester South,
Leicester Town Hall Square,
Leicester.
LE1 9BG
5th November 2014
Dear Mrs Mason
Re: Regulation 28 Report to Prevent Future Deaths
I acknowledge receipt of the Regulation 28 - PFD report from your office ,
dated 18th September 2014,in which you request to be advised of any actions
that have been taken to improve and oversee the preparation and conclusion
of RCA (Root Cause Analysis) Investigation reports; and suggest that
consideration be given to introducing a system to re-open any such reports
found to be inadequate or erroneous.
First, I would like to apologise that, on this occasion, the root cause analysis
investigation report was not helpful. I accept that information was presented
by clinicians at inquest that was not covered in the RCA report and this must
have been frustrating for your assistant deputy who heard this inquest.
However, the purpose of these internal patient safety investigations is to learn
lessons and implement solutions which prevent recurrence. By their very
nature, they often contain differing clinical opinion and judgements. We use
the RCA reports as a tool for listening, learning and improving, as well as
providing a documented account of the facts for the patient/family.
The Trust continually works to improve the quality of the investigations of the
RCA reports and we have recently introduced three further measures to assist
with this.
1. From April 2014, the Trust has established a process whereby each RCA
investigation has a named 'Chair'. This individual is either the Medical
Director or Chief Nurse or one of their nominated deputies (i.e. Deputy
University Hospitals of Leicester NHS Trust includes
Glenfield Hospital, Leicester General Hospital and Leicester Royal lnfinnary
Website: www. leicestershospitals.nhs.uk ·
Medical Director, Director of Safety and Risk, Deputy Ch ief Nurse). The
RCA Chair will review the terms of reference and scope of the
investigation ; ensure
team has been
established and ensure that an adequate ('SMART') action plan is
produced. In addition to the Clinical Management Group (CMG) Director,
the RCA Chair will also sign off the report.
the appropriate
investigation
2. The Trust has recently purchased external expert RCA training :-
Basic RCA training for investigation leads.
RCA Masterclass training for senior patient safety investigators.
RCA Oversight training for RCA Chairs.
3. The Trust has established a new 'Adverse Events Committee', reporting to
the Executive Quality Board, to review all serious untoward events (SU ls).
This new Committee will ensure sufficient senior scrutiny is given to the
events
that cause avoidable death and . harm. A collective
understanding of the root causes, the themes and the actions required
to reduce similar failings is required to ensure appropriate safety
workstreams are in place.
The Adverse Events Committee will provide a systematic review of
every action plan, tracking all actions to full implementation.
With respect to re-opening investigation reports, the Tr.ust does consider any
feedback received from Commissioners and may make amendments to such
reports if there is compelling evidence to do so.
I hope that this provides you with assurance that we strive to provide
comprehensive and accurate reports. Although these reports are not written
for any legal purposes, either claims or inquests, we are very willing to share
them externally should they be useful to you.
We always welcome feedback from your office and whilst I ful ly understand
your concern regarding the RCA Investigation in this case, I was a little
surprised that it has resu lted in a Regulation 28 Report. However, we note
your concerns and strive to continue to improve our investigation and
reporting processes as detailed above.
Yours sincerely,
Chief Executive
University Hospitals of Leicester NHS Trust includes
Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary
Website: www. leicestershospitals.nhs.uk
Cc:
, Director of Corporate and Legal Affairs
, Chief Nurse
, Director of Safety and Risk
, Assistant Director (Head of Legal Services)
University Hospitals of Leicester NHS Trust includes
Glenfield Hospital, Leicester General Hospital and Leicester Royal lnfinnary
Website: www.leicestershospitals.nhs.uk
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