Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0468, written 27 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Oct 2014 |
|---|---|
| Reference | 2014-0468 |
| Deceased | Jackson Mitchell |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 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, NHS England, PO Box 16738, Redditch B97 9PT 2. The Chief Executive, Norfolk & Norwich University Hospital NHS Foundation Trust, Colney Lane, Colney, Norwich . 3. The Chief Executive, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, Gayton Road, King’s Lynn PE30 4ET 41 | CORONER | am JACQUELINE LAKE senior coroner, for the coroner area of NORFOLK 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 12 May 2014 | commenced an investigation into the death of JACKSON TERRY SELLERS MITCHELL, AGE 6 DAYS: The investigation concluded at the end of the inquest on 15 OCTOBER 2014, The medical. cause of death was 1(a) INTRAPERITONEAL EXTRAVASATION OF PARENTERAL NUTRITION SOLUTION AS A CONSEQUENCE OF 1(b) UMBILICAL VEIN CATHERTERISATION and PART II PREMATURITY and the conclusion of the inquest was DEATH DUE TO A RARE BUT RECOGNISED RISK OF NECESSARY MEDICAL TREATMENT. 4 | CIRCUMSTANCES OF THE DEATH Jackson was born prematurely at 31 weeks gestation at Queen Elizabeth Hospital, Kings Lynn with a low birth weight of 1.78 kilograms. An umbilical venous catheter (UVC) was inserted to give parenteral nutrition feeding and fluid management. A heart murmur was detected on the morning of 8 May 2014. On evening of 8 May 2014 Jackson developed abdominal distension. In the light of the clinical picture a diagnosis was made of necrotising enterocolitis. Evidence was given that in the light of the presenting symptoms this was a reasonable diagnosis to make. A nasogastric tube was inserted to drain the fluids, Jackson was placed on nil by mouth and triple antibiotics were started. ; -Jackson required cardio-pulmonary resuscitation. Arrangements were made for transfer to Norfolk & Norwich University Hospital (NNUH) which occurred at 8:40 am.on 9 May 2014. A surgical drain was inserted and milky fluid was aspirated. The neonatal team at NNUH felt the presentation was due to extravasation of total parenteral nutrition solution and not necrotising enterocolitis. A large amount of fluid was drained before and after Jackson's transfer to the NNUH. - The UVC was removed. Jackson continued to deteriorate and he died at 05:05 on 10 May 2014. Post Mortem Report gives the cause of death as 1a) intraperitoneal extravasation of parenteral nutrition solution b) Umbilical vein catheterisation 2. Prematurity. The Post Mortern identified damage to Jackson's liver compatible with injury from the parenteral nutrition solution, which is currently deemed to be a “very rare” complication. There was no evidence of direct vessel perforation from the umbilical venous catheter tip. 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 untess action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - The damage found to Jackson’s liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it. Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T 10 vertebral level. The UVC in this case was found to be in a lower lying position, but one which is presently acceptable to 80% of Doctors. There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period. Extravasation was shown following routine screening of ultra sound scans, although in the study there were no fatalities. Most of the complications in the study occurred with low lying catheters. ' Further investigation is being carried out into the positioning of catheters and problems of extravasation of the fluid from UVC. It is understood NHS England are looking into whether any lessons can be learned from this case. No criticism was expressed at the inquest of any of the medical team involved in the care of Jackson. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. The purpose of this Report is to see whether there are any learning points for the wider NHS and Neonatal Doctors and Nurses. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by. 29 December 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 | 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. DATE 27 October 2014 SIGNED BY CORONER
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.
The Queen Elizabeth Hospital NHS) King’s Lynn NHS Foundation Trust 204 The Queen Elizabeth Hospital 4 20% Gayton Road Kings Lynn Norfolk PE30 4ET www.qgehkl.nhs.uk Your ref: jUtmp Chief Executive Tel: Date: 14° January 2015 Fax: Minicom: 01553 613888 Ms. J Lake LL.M E-mail: Senior Coroner for Norfolk 69 — 75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms. Lake, Re: Regulation 28 report following the Inquest into the death of Jackson Terry Sellers Mitchell Thank you for your letter of the 8" January 2015, which was received yesterday, requesting an immediate response to your Regulation 28 Report following the Inquest into the death of Jackson Terry Sellers Mitchell. | understand that you sent this report to the former Chief Executive on the 27" October 2014 but unfortunately we have been unable to find any record of its receipt.in the organisation, hence’ our unfortunate lack of response. | apologise that this failure to respond has occurred and | would like to offer you my assurance that this matter was acted upon at the time by the clinical team involved and continues to be monitored by the Trust. | have as a matter of urgency contacted all the relevant clinical staff and have requested an immediate update on the actions that were undertaken following the death of baby Jackson and have asked them to appraise me in detail of what has been done to ensure learning for the neonatal team within this Trust and across the wider NHS. An internal review took place within the Trust using a root cause analysis approach and | understand that this was presented at the Inquest. The report concluded with an action plan that focused on training and learning for staff at a local level and at a broader Network level. This action plan has since been followed up and expanded upon. Locally the learning from the internal investigation and the outcome from the Inquest were discussed and shared at the paediatric governance meetings. A new X-ray review checklist was introduced which requires that all X-rays undertaken have to be reviewed and signed by a senior clinician. This includes those X-rays which are taken to check on the position of lines-and tubes. This will ensure that it will always be a senior clinician that approves the position of lines. Chain _.* Edward Libbey, Chief Executive: Dorothy Hosein * Patron: Her Majesty The Queen 19 January 2015 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust The learning from this incident was incorporated into the Regional Skills Day that took place on the 8" October 2014 and will be addressed again this year at the next Skills Day, which is due to take place on the 13" October 2015. In advance of any work that is being done nationally, the regional guidelines for umbilical venous catheterisation are currently being revised by HI at the Norfolk and Norwich University Hospital and a draft set of guidelines has been circulated to all the paediatric teams in the region for consultation and comment. Once those comments have all been reviewed and any amendments made, these guidelines will be subject to ratification and will be implemented throughout the region. In the interim, practice here at King’s Lynn is already in accordance with these new recommendations, Nationally, Po the Patient Safety Lead for Maternity and the Newborn at NHS England, convened a meeting in October last year in conjunction with the British Association of Perinatal Medicine (BAPM) to discuss the formation of a small group to review current practice and formulate new national guidance. The group is intending to review the literature on the matter and utilise the clinical experience of clinicians who have experienced difficulties with using venous lines, to produce a Framework for practice for all central venous lines. The clinical aspect of this work will be led by BAPM but NHS England will support by providing any relevant safety facts and by assisting with the dissemination of the Framework once completed. | understand that the working group will also incorporate a person with a link to the National Institute for Health and Care Excellence so that the Institute is fully aware of the recommendations of the working group. The working group will submit their report and recommendations to the membership of BAPM for comment before the final Framework is published and circulated. This is unlikely to occur before autumn 2015. | hope that | am able to assure you that this matter is under significant review locally, regionally and nationally and will ultimately result in a new Framework for practice that will support healthcare professionals in managing this difficult area of care and treatment. It is hoped that this will ensure that the entire NHS learns from this tragic event and will improve the care and management of such vulnerable babies in the future. May | apologise once again for our failure to provide you with a more timely response. Yours sincerely, Dorothy Hosein Chief Executive Page 2 of 2
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