Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0421, written 26 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 | 26 Sep 2014 |
|---|---|
| Reference | 2014-0421 |
| Deceased | Emmanuel Akinmuyiwa |
| Coroner | Louise Hunt |
| Coroner area | Birmingham & Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. NHS England
2. Commissioning groups
{ | CORONER
| am Louise Hunt, Senior Coroner, for the coroner area of Birmingham and Solihull
2 | 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.
3 | INVESTIGATION and INQUEST
On 18/02/13 | commenced an investigation into the death of Emmanuel Tobiloba
Akinmuyiwa. The investigation concluded at the end of the inquest on 12 September
2014. The conclusion of the inquest was that the deceased died from 1a. Cardiac failure
due to 1b. Severe anaemia due to ‘1c sickle cell disease. | recorded a narrative
conclusion as follows:
Emmanuel died on the 11'" February 2013 as a result of severe anaemia caused bya
sickle cell crisis. During his admission there was a gross failure to check his HB on
10/02/13 and a failure to provide an earlier blood transfusion. On balance earlier
monitoring of his haemoglobin and an earlier blood transfusion would have avoided his
death. His death was contributed to by neglect.
4 | CIRCUMSTANCES OF THE DEATH
Emmaunel was a 7 year old boy who suffered from sickle cell disease. On 08/02/13 he
was referred to Birmingham Heartlands Hospital and found to have a HB of 5.7. He was
diagnosed as being in sickle cell crisis. On 09/02/14 his HB was 5. Instructions were left
that he should have a further blood test taken on 10/02/13. A junior doctor decided not
to undertake that test as Emmanuel looked clinically well. On 11/02/13 his HB was
checked. The result was available at 4pm and confirmed a level of 2.8. At 20.30 he was
given a transfusion. At 21.50 he got up to toilet and collapsed. He could not be
resuscitated and died.
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. —
Evidence at the inquest confirmed that there needed to be a clear protocol in the West
Midlands for the management of patients with Sickle ceil disease. Ordinarily they are
managed at Birmingham Children’s hospital. In this case as Emmanuel was admitted to
Heartlands hospital various telephone calls were made to Birmingham Children’s
hospital. It was acknowledged in an internal investigation by Birmingham Heartlands
hospital that staff had a lack of knowledge and appreciation for the signs and symptoms
of a sickie cell crisis and what treatment was necessary. | was informed at the inquest
that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease
with clear guidelines and protocols for how and where patients should be treated. i was
informed that this had not happened to date due to the lack of funding available to liaise
with ali local hospitals and produce and put in place such protocol and guidance. A lack
of guidelines and protocols for the West Midlands means future patients are at risk of
death.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you 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 Friday 21° November 2014. |, 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:-
Emmanuel’s family
| have also sent it to the Birmingham Heartlands hospital and Birmingham Children’s
hospital who may find it useful or of interest.
lam 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.
26" September 2014
foetus
[SIGNED BY CORONER]
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