Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0478, written 4 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2014 |
|---|---|
| Reference | 2014-0478 |
| Deceased | Mark Hudson |
| 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 | 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. 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 3rd September 2013 an investigation commenced into the death of Mark Bentley
Hudson aged 50 years. The investigation concluded at the end of the inquest heard on
8th October 2014.
The record of the inquest confirmed as follows:
The Medical cause of death was
Ia Myocardial Infarction
1b Severe Coronary Artery Disease and Thrombosis of the Right Coronary Artery
Bypass Graft
11 Left Pulmonary Embolus and Diffuse Alveolar Damage
The conclusion of the Coroner as to the death was a Narrative conclusion as follows:
Mark Bentley Hudson was admitted to hospital on 20th August 2013 following
three days of intermittent chest pain. After assessment he underwent urgent
coronary artery bypass graft surgery. Although he initially appeared stable he
went into cardiac arrest at approximately 22.45 hours on 25th August 2014
necessitating cardiopulmonary resuscitation. At approximately 00.10 hours on
27th August 2014 he again suffered a cardiac arrest. Efforts were made to ventilate
him. Oesophageal intubation went unrecognised until the arrival of an
anaesthetist. Despite efforts to revive him, death was pronounced at 01.15 hours
later that morning.
4
CIRCUMSTANCES OF THE DEATH
See the contents of section 3 above.
1
The inquest was informed that further to admission to hospital on 20th August 2013 and
having undergone urgent and necessary cardiac surgery, the Deceased had suffered a
cardiac arrest on 25th August 2013 but had been resuscitated and stabilised.
However just after midnight on 27th August 2014 he went into ventricular fibrillation.
Evidence was heard that a telephone call was made by staff on the Cardiac Intensive
Care Unit [CICU] that the on - call Anaesthetist be bleeped with a view to her attending
to provide assistance for Mr. Hudson. Shortly afterwards, the Anaesthetist having failed
to appear at the CICU, two further requests were made by CICU staff for the
Anaesthetist to be contacted.
An Anaesthetist gave evidence to the effect that she does not recall receiving the first
two of those requests to attend CICU.
When the Hospital Trust undertook a Sudden Untoward Incident Review, it could not be
established that the requests made by CICU staff had been received and acted upon.
Switchboard staff are not expected to maintain a contemporaneous record of the calls
they receive which require switchboard staff to then contact the Anaesthetist. The author
of the internal review did accept that she could not rule out the possibility that the
Anaesthetist had not been contacted in response to the first two requests and that the
CICU staff had effectively been trying to maintain the Deceased’s airway whilst
expecting the Anaesthetist to arrive imminently when she had not actually been notified.
At the inquest this appeared to be an issue that had not been fully appreciated during
the Hospital Trust’s internal review.
Ultimately, the Anaesthetist did attend CICU to learn that a Surgical Registrar had -
given the non appearance of an Anaesthetist - decided to take over airway management
and attempted to intubate the Patient but that his airway had been compromised given
that intubation had been carried out incorrectly.
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 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.
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 that have been / are being taken internally at the
Hospital further to this death, I remain concerned that there is a real risk that when the
need arises for urgent provision of specialist care within the CICU department, such
requests may go unanswered or be delayed. If CICU staff request such assistance via
the Hospital Switchboard personnel at the hospital, I am concerned that the procedures
in place are insufficiently robust to the extent that requests may not be followed up
appropriately and to the potential detriment of the Patient requiring that urgent help.
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
2
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 30thDecember 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 Mark Bentley Hudson
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: 4th November 2014
3
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.
Blackpool Teaching Hospitals INHS| NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR — 01253 306993 22 December 2014 Mr Alan Wilson HM Corner Blackpool & Fylde Coroner's Office — Municipal Buildings PO Box 1066 Corporation Street Blackpool FY1 1GB Dear Mr Wilson Re: Mark Bentley Hudson (Deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths dated 4 November 2014 arising from the Inquest touching upon the death of Mark Bentley Hudson. The Trust has a strict procedure in place which has been drafted in line with the Resuscitation Council (2010) Resuscitation Guidelines. In July 2012 the process used by the Resuscitation Council (UK) to produce the 2010 Resuscitation Guidelines was accredited by the National Institute for Health and Clinical Excellence (NICE). The NICE Accreditation Scheme recognises organisations that demonstrate high standards in producing health or social care guidance. Users of NICE accredited guidance can therefore have high confidence in the quality of the information provided. The Trust's procedure is aimed primarily at healthcare professionals who are first to respond to an in-hospital cardiac arrest and is enclosed for your attention. For all in-hospital cardiac arrests help is summoned using a standard telephone number (2222) and cardiopulmonary resuscitation (CPR) is started immediately. All new staff members within the Cardiac Division are made aware of the 2222 procedure during their induction training. The cardiac arrest bleeps are tested at the commencement of each shift and if there is a failure of response the switchboard operators follow this up. The 2222 number alerts the switchboard to any medical emergency within the Trust and for this very reason all the 2222 calls are recorded for training and development purposes. The switchboard staff, prior to lone working, follow a strict training programmes and have to satisfy a stringent list of competencies before they are allowed to answer the 2222 calls. They must also feel confident that they are ready to receive and deal with the call. The switchboard department has advanced software technology which will enable the supervisor to field medical emergency calls to certain, more experienced members of the switchboard team. As you are aware the Trust has implemented the recommendations made following the serious untoward investigation into the circumstances s' ing Mr Hudson's death. It is clear that the Trust has learnt from this incident and as Matron advised at the hearing, to her knowledge, within the Cardiac unit there has not been any other similar incident. RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROWS CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. Patient Safety Chairman: Mr lan Johnson M.A., LL.M. Chief Fxecutive: Mr Gary Doherty The @& Information © Standard Gold YO, INVESTORS | Xu IN PEOPLE ! Blackpool Teaching Hospitals NHS} NHS Foundation Trust That said, as the Trust continually moves forward to improve its service, in addition the Resuscitation Team have undertaken training with senior members of the CICU Team. Those senior members of the team are now competent in the placement of iGel tubes, which are easier to place than a formal tracheal tube and will allow satisfactory ventilation of a patient until expert help arrives. We have adopted a policy of using end tidal carbon monoxide monitoring for all intubated patients. This technology allows rapid identification of inappropriate tube placements. The Trust also commissioned a review of our Out of Hours Anaesthetic Service from the Royal College of Anaesthetists. That report was received on 13 November 2014 and we are currently working our way through its recommendations in a further effort to improve our service. The final action which has been taken is to convene a meeting of myself with the Head of Resuscitation, the Head of Department for Cardiac Anaesthesia and the Matron for the CICU to discuss whether we need to make any further modification to our process. | hope the above satisfies your concern. Yours sincerely Ma Dov. PROFESSOR MARK O’DONNEL MEDICAL DIRECTOR ae a
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