Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0464, 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 | 2014-0464 |
| Deceased | Jude Kliem |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay & South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being set to: e Secretary of State for Health Coroner lam IAN MICHAEL ARROW. Senior Coroner for the area of Plymouth, Torbay and South Devon. 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. Investigation and Inquest On 3 June 2013 | commenced an investigation into the death Jude Daniel Kliem, then aged one year. The investigation concluded at the end of the inquest on 8 August 2014. The cause of death was found to be: ta Idiopathic Pulmonary Arterial Hypertension The conclusion of the inquest was that Jude Daniel Kliem died from Natural Causes. Circumstances of death The deceased was being treated at Derriford Hospital in Plymouth. Attempts were made by different Consultant Doctors to arrange a transfer to Bristol and to Southampton. Coroner’s concerns There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation Action should be taken | would ask you please to review the method of referral of seriously sick patients between Hospitals so that lines of communication are clear. You may wish to note that Derriford Hospital has reviewed its processes and made improvements since the death. lam attaching supplementary documents. Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 October 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 — | and fF (family) and (Trust's Solicitors) | 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. IM ARROW Date 29 August 2014 Senior Coroner — Plymouth Torbay and South Devon area
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.
acl From Dr Dan Poulter MP @r9 Parliamentary under Secretary of State for Health Richmond House Department 79 Whitehall London of Health SWIA 2NS Tel: 020 7210 4850 POCS 884128 Mr I Arrow HM Coroner Coroner’s Court 3 The Crescent Plymouth PL1 3AB 23"! October 2014 Dear Mr Arrow, Thank you for your letter following the inquest into the death of Jude Kliem. I was sorry to read of Jude’s death and wish to extend my sincere sympathies to his family. Jude was being treated at Derriford Hospital in Plymouth where various attempts were made by different consultant doctors to arrange for him to be transferred to Bristol and Southampton hospitals. You are concerned that there appears to have been a breakdown in communications between the hospitals involved. You ask that we: review the standardisation of patient retrieval within the NHS e review the methods of referral of seriously sick patients between hospitals so that lines of communication are clear e consider standardising documentation to improve communication At the inquest, you heard that changes have already been made by Derriford hospital for the transfer of paediatric intensive care patients to other hospitals, including the development of a standard pro-forma referral document. This bring them into line with the policy and standard practice of most other paediatric intensive care units (PICUs) in England because of the need to ensure prompt referral and safe transfer of patients who need paediatric intensive care. Ihave shared your report with NHS England. I am advised by its clinical experts working in networks covering both PICUs and PICU retrieval services. Most PICUs already use a pro- forma for patient referral and retrieval (similar to the pro-forma you provided from Bristol Royal) to ensure a structured way of communicating the information required. These pro- forma have been developed either by the individual hospitals or by agreement across a region. : There is clearly an opportunity to further improve safety by bringing together the best aspects of the existing formats into a single document. Such a document would contain the key content needed for safe and effective referral and retrieval, to which suitable local or specialist requirements might be added. In developing such a national document the PICU networks would build on standards and service specifications already in place, such as ‘The acutely or critically sick or injured child in the district general hospital - a team response’ (Department of Health, 2006). There is relevant work currently underway, led by the Paediatric Intensive Care Society’s Acute Transport Group, on setting standards for the skills and competencies needed by staff who transfer babies and children in need of PICU. NHS England intends to take this forward in partnership with the Paediatric Intensive Care Society. Together, they will work to ensure that a national format is not seen as a stand- alone solution, but part of a much wider process that facilitates a senior clinical conversation. The aim is to ensure that both family and clinical concerns are effectively addressed and lead to agreement on appropriate action. There are several examples of this being already being done successfully in the NHS, and I understand that the organisations that were involved in Jude’s care are now working on introducing a similar model. I have asked my officials to keep you up to date with the progiess of this work over the coming months. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Jude’s death to my attention. Best wishes, DR DAN POULTER
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