Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0493, written 7 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 | 7 Nov 2014 |
|---|---|
| Reference | 2014-0493 |
| Deceased | Colin Ireland |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (West) |
| Category | State Custody related deaths |
| Organisation named | Mid Yorkshire Hospitals NHS Trust |
| 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.
ANNEX A
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:
The Director
High Security Prisons Group
Carnarvon House
HMP Manchester
Southall Street
Manchester
M60 9AH
1 | CORONER
tam David Hinchliff, Senior Coroner for the coroner area of West Yorkshire (Eastern).
2 | CORONER'S LEGAL POWERS
| make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
ani i 8 and 29 of the Coroners (Investigations) Regulations 2013.
3 | INVESTIGATION and INQUEST
On 28" February 2012, | commenced an investigation into the death of Colin John
Ireland (aged 57). The investigation concluded at the end of the inquest on 24" October
2014. The conclusion of the inquest was:-
1a Pulmonary Thromboembolism
b Deep Venous Thrombosis of the left leg
c A Fracture to the left hip (operated).
Jury’s narrative conclusion
Having considered the evidence, we the Jury find Mr Iretand’s death was accidental in
nature and not caused by the action or inactions of any other person or persons at
Pinderfields Hospital, Wakefield or HMP Wakefield.
On the morning of 11" February 2012, Colin John Ireland accidentally fell while taking
routine exercise in the yard at HMP Wakefield. Mr Ireland was then transferred to
Pinderfields Hospital, Wakefield and was diagnosed with a fracture of the left femur. On
13” February 2012, Mr Ireland underwent full hip replacement surgery and was
discharged on 17" February 2012 to HMP Wakefield’s Health Care Centre. On 21%
February 2012, Mr Ireland was found collapsed in his cell, after attempts of
resuscitation, he was pronounced dead at 0924 hours.
4__| CIRCUMSTANCES OF THE DEATH
1.
Colin John tretand had been sentenced to life imprisonment with a whole life
tariff in 1993. He had been at HMP Wakefield since March 2008.
He was a diabetic and there were times when he ignored medical advice in
respect of this which led to complications arising from poor management of his
diabetic condition and him suffering with poor vision.
During icy weather on 11" February 2012 and whilst taking exercise in the
exercise yard, Mr Ireland slipped and fell fracturing his left hip.
Despite verbal advice from a GP to an experienced nurse that this was a life-
threatening condition and that Mr Ireland should have been sent to hospital
immediately, there was a delay of three and a half hours whilst a Governor
Grade Officer insisted on the attendance of a GP and having made several
attempts to obtain permission from the Prison Service Directors for him to leave
the Prison having regard to his high security status.
Mr Ireland’s surgery, which was uneventful, did not take place until Monday, 13"
February 2012. He was given the appropriate anti-coagulant drugs to reduce
the risk of deep vein thrombosis and pulmonary embolism although there were
missed doses which according to Expert evidence on balance of probability did
hot cause or contribute to his death.
He was discharged to the Prison’s Healthcare Centre at approximately 5.00 pm
on 17" February 2012. He needed considerable assistance with mobility of the
activities of daily living. He was meant to receive continued anti-coagulant
medication but there were missed doses which according to Expert evidence on
balance of probability did not cause or contribute to his death.
On the morning of Monday 21" February 2012, whilst using the toilet he was
found in a collapsed state. Resuscitation attempts were unsuccessful and his
death was confirmed by paramedics at 09.24 hours on 21° February 2012,
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. —
1.
That a Governor Grade Officer who had sole responsibility for the running of the
Prison challenged the clinical judgement and decisions of both an experienced
nurse and the on-call GP who believed that Mr Ireland had fractured his hip and
that this was a potentially life-threatening condition and that he should be sent to
hospital as an emergency.
That the same Governor Grade Officer had difficulty in contacting by telephone
the on-call Operational Manager for the High Security Prison
Group to seek permission for Mr Ireland to be sent to hospital. Apparently,
was not responding to her cails. | request that the Director of the
High Security Prison Group specifically address this issue in response to this
report. Fortunately, the Governor had through his own dealings with
who was then the Director of High Security Prisons, his contact details
who was then able to give the relevant permission. | understand that this was
an unofficial approach which | do not criticise bu Id point out that other Duty
Governors may not have had access eee which would
have lengthened the delay. It occurs to me that the on-call system is flawed and
should be reviewed
3. That the Governor Grade Officers who gave evidence had differing views as to
the action to be taken, in particular in relation to seeking approval from the High
Security Prisons Group regarding release to hospital in such circumstances. |
consider that there should be an agreed protocol for this and that all on-duty
Governors should receive appropriate training regarding responding to medical
emergencies of all types to ensure a speedy release to hospital when
necessary, obviously without prejudicing appropriate security issues.
Although the Duty Governor claimed to acknowledge that preservation of life
was paramount, he appeared to be more motivated by Mr freland’s notoriety
than to the serious issues of his condition which created an unacceptable delay.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] 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 2 January 2015. 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons [NAMES]. | have also sent it to [NAMED PERSON] who may find it useful or of
interest.
{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.
7™ November 2014
Senior Coroner
West Yorkshire (Eastern)
ANNEX A
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:
Medical Director
Mid Yorkshire Hospitals NHS Trust
Trust Headquarters & Education Centre
Pinderfields General Hospital
Aberford Road
Wakefield
WF1 4DG
1 | CORONER
| am David Hinchliff, Senior Coroner for the coroner area of West Yorkshire East.
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and a 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 | INVESTIGATION and INQUEST
On 28" February 2012, | commenced an investigation into the death of Colin John
Ireland (aged 57). The investigation concluded at the end of the Inquest on 24" October
2014. The conclusion of the inquest was
1a Pulmonary Thromboembolism
b Deep Venous Thrombosis of the left leg
c A Fracture to the Left Hip (operated).
Jury’s narrative conclusion
Having considered the evidence, we the Jury find Mr Ireland's death was accidental in
nature and not caused by the action or inactions of any other person or persons at
Pinderfields Hospital, Wakefield or HMP Wakefield.
On the morning of 11" February 2012, Colin John Ireland accidentally fell while taking
routine exercise in the yard at HMP Wakefield. Mr Ireland was then transferred to
Pinderfields Hospital, Wakefield and was diagnosed with a fracture of the left femur. On
43" February 2012, Mr Ireland underwent full hip replacement surgery and was
discharged on 17" February 2012 to HMP Wakefield's Health Care Centre. On 21%
February 2012, Mr ireland was found collapsed in his cell, after attempts of
resuscitation, he was pronounced dead at 09.24 hours.
4 | CIRCUMSTANCES OF THE DEATH
1. Colin John Ireland had been sentenced to life imprisonment with a whole life
tariff in 1993. He had been at HMP Wakefield since March 2008.
He was a diabetic and there were times when he ignored medical advice in
respect of this which led to complications arising from poor management of his
diabetic condition and him suffering with poor vision.
During icy weather on 11" February 2012 and whilst taking exercise in the
exercise yard, Mr Ireland slipped and fell fracturing his Jeft hip.
Despite verbal advice from a GP to an experienced nurse that this was a life-
threatening condition and that Mr Ireland should have been sent to hospital
immediately, there was a delay of three and a half hours whilst a Governor
Grade Officer insisted on the attendance of a GP and having made several
attempts to obtain permission from the Prison Service Directors for him to leave
the Prison having regard to his high security status.
Mr Ireland’s surgery, which was uneventful, did not take place until Monday, 13°
February 2012. He was given the appropriate anti-coagulant drugs to reduce
the risk of deep vein thrombosis and pulmonary embolism, although there were
missed doses which according to Expert evidence on balance of probability did
not cause or contribute to his death.
He was discharged to the Prison’s Healthcare Centre at approximately 5.00 pm
on 17'" February 2012. He needed considerable assistance with mobility of the
activities of daily living. He was meant to receive continued anti-coagulant
medication but there were missed doses which according to expert evidence on
balance of probability did not cause or contribute to his death,
On the morning of Monday 21° February 2012, whilst using the toilet he was
found in a collapsed state. Resuscitation attempts were unsuccessful and his
death was confirmed by paramedics at 09.24 hours on 21° February 2012.
CORONER'S CONCERNS
41.
Mr Ireland, on admission to Pinderfields General Hospital on 14" February 2012
was prescribed Thromboprophylaxis medication in the form of Clexane 40 mg
which he received on 11", 12", 14", 15" and 16"" February 2012. Two doses
were missed namely 13” and 17" February 2012. Although an Expert opinion is
that the two missed doses would not on balance of probability have caused or
contributed to his death, | consider that action should be taken to prevent
omissions of such important medication and that an explanation should be given
as to why the doses were omitted. The Orthopaedic Surgeon who carried out Mr
Ireland's operation did not consider it inappropriate for him to be given his
Clexane on 13" February 2012 i.e. the day of surgery. Furthermore, a Junior
Doctor did not complete a documented risk assessment for venous
thromboembolism. Although this did not affect the actual prescribing, | require
the Trust to tighten it’s procedure in ensuring that the appropriate risk
assessments are correctly and appropriately completed.
Regarding Mr Ireland’s discharge to the Prison's Healthcare Centre on 17"
February 2012 at approximately 5.00 pm. Mr Ireland was given an inadequate
discharge summary which did not make clear that he had not received his anti-
coagulant medication, Clexane, that day. Health Care Officers were unaware of
this and therefore he did not receive this medication on his return to the Prison
that day. The discharge summary should have made it absolutely clear as to the
treatment plan once discharged. There was a requirement for physiotherapy,
yet no enquiries were made about the availability of physiotherapy during the
weekend period, which does not exist at the Prison and therefore alternative
arrangements were not considered.
3. | invite the Trust to review it’s discharge procedures generally. Specifically |
consider that the discharge of patients late on Fridays when healthcare services
and facilities over a weekend period are severely limited, both in terms of Prison
health care and in the wider community can be risky. Although | appreciate that
hospital places are often scarce and in demand ! urge the Trust to consider the
merits of avoiding late Friday discharge when enquiries have not been made as
to the availability of adequate health care provision over a weekend period. In
this instance, Mr Ireland would still have been at high risk of developing a deep
vein thrombosis and pulmonary embolism, which in fact he did, which was the
cause of his death the following Monday.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] 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 Qn January 2015. |, 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 [NAMES]. | have also sent it to [NAMED PERSON] 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.
7° November 2014
Seniof’Coroner
West Yorkshire (Eastern)
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