Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0506, written 21 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 | 21 Nov 2014 |
|---|---|
| Reference | 2014-0506 |
| Deceased | Tracey Bannister |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Walsall Healthcare NHS 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Walsall Healthcare NHS Trust 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of Black Country. 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 30 June 2014, I commenced an investigation into the death of Tracey Bannister. The investigation concluded at the end of the inquest on 20 November 2014. The conclusion of the inquest was the deceased died on the 26 June 2014 from 1a. Sepsis due to 1b) Fulminant hepatic failure due to 1c) Biliary obstruction and 2) Obesity. I recorded a conclusion of Natural causes. 4 CIRCUMSTANCES OF THE DEATH 1. Tracey Bannister was a 29 year woman with a medical history of gall stones and right upper quadrant pain. 2. She had Endoscopic Retrograde Cholangio-Pancreatography surgery (ERCP procedure) on a number of occasions to remove the gall stones during 2013 and 2014. 3. She returned for repeat elective ERCP on the 24 June 2014 to remove a stent. She consented to the procedure and the old stent was removed. There were some fragments of stone and debris found which came out with the stent removal. She was then transferred to the recovery area and subsequently discharged. A further follow up appointment was then made to deal with the management of any remnants of gall bladder and stones in two weeks time. 4. She was given a discharge leaflet which explained if she continued to feel unwell or symptoms of pain worsened then she should contact her GP in the first instance. 5. When she arrived home she complained of feeling unwell and stayed in bed. On the morning of the 26 June she continued to feel unwell and then telephoned for an ambulance. She was taken to the A and E department and arrived at 9.16am at Manor Hospital. She appeared cyanosed with low blood pressure and BM 1.2mmol. 6. Blood gases revealed she was acidotic and she deteriorated and arrested. She suffered a cardiac arrest and was declared deceased at 10:22 hours. 1 [IL1: PROTECT] 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. – There are well documented and recognised risks of ERCP surgery. These include: Inflammation of the pancreas (pancreatitis) 2-4% Infection in the bile duct (cholangitis). This is usually treated with antibiotics, but occasionally can be serious. A hole may be made in the bowel (perforation) and if this happens surgery may be necessary. Bleeding may result from the ECRP, which will usually stop quickly by itself. In severe cases, a blood transfusion or operation may be needed to control the bleeding. My concern is that patients should be advised not only to contact their GP but also the department where surgery had been performed if symptoms of pain, raised temperature continue for more than 24 hours. In this case medical evidence suggested that had she attended Hospital twenty four hours earlier then the outcome may have been different. Therefore, you may consider that the information and advice given to patients on discharge may need to be altered to take into account the lessons learnt from this inquest. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you 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 15 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons and Ms Bannister’s family. 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 21 November 2014 2 [IL1: PROTECT]
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.
Walsall Healthcare Patient Safety Department Manor Hospital Moat Road Walsall West Midlands WS2 9PS Tel. Email Website . Our Ref. Your Ref Regulation 28 REPORT Date. 14 January 2015 MrZSiddique HM Coroners Office Crocketts Lane Smethwick B66 3BS Dear Mr Siddique Re: Tracey Bannister deceased Date of Birth: 16th August 1984 Date of Death: 26th June 2014 Date of Inquest: 20th November 2014 I am writing in response to your report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I fully accept that although the inquest verdict on Ms Bannister’s death was natural causes, the circumstance of inadequate discharge information gives nse to the potential for an ongoing risk to future patients. I would like to take the opportunity to assure you that as an organisation. we have formal processes for investigating serious incidents. We have taken this case senously and have conducted a full review. To this end, a Root Cause Analysis was completed which included a review of the systems in place for maintaining safety at the time The learning from both the Inquest and the internal investigation will be shared with staff across the organ isation. Summary of Incident Ms Banrister underwe a repeat elechve E9doscomc Retrograde CholargioPancreatogranhy ERCP) o the 24 Ju e 2014 o ornove a stent Sre c r sented to the rocedure and the o d s4ent was removed th ste enca S we There were s me agrrents of stone and debNs our.d whic came cut wit casre eo 0’ toe roe’ arcc i0erc 0e cbee ahoos ;-re. eo’ed .‘t 02 ep’rtors D2 aturcrs ‘e ooqca ‘atus and ‘ar eve here a ser ed Tcsevat o paarec sa M Ba ret aade to de:vh’ 0’e ma,agemnr off any ern’arts r ‘a ‘jLeeucn’Iv c argod / ga cioae, end cTnes C 3 eeos znm tr rc wu p . e as o ‘s tore ver BC ta v k s i ic M Barr s e At t e tir e o the i de was given The eaflet expianed f she contued to fee unwefl or syn’ntons of pain Norsened ther, she should contact her GP n the first nstarce t sed a d sc arge for at t o B doscopy af e r ca . r r’ v’ .I’i Bke tc ar’’ L r,. r’ Shortly after arrival Ms Bannister went into cardiac arrest, however resuscitation was unsuccessful and she was pronounced deceased at 1O.22hrs Coroners Concerns During the course of the inquest the evidence revealed matters giving rise to concern. In the Coroner’s opinion there is a risk that future deaths will occur unless action is taken. The MATTERS OF CONCERN are as follows, - There are well documented and recognised risks of ERCP surgery. These include: Inflammation of the pancreas (pancreatitis) 2-4% 1 Infection in the bile duct (cholangitis). This is usually treated with antibiotics, but occasionally can 2. be serious. 3. A hole may be made in the bowel (perforation) and if this happens surgery may be necessary. Bleeding may result from the ECRP. which will usually stop quickly by itself. In severe cases, a 4. blood transfusion or operation may be needed to control the bleeding. The Coroners concern is that patients should be advised not only to contact their GP but also the department where surgery had been performed if symptoms of pain, raised temperature continue for more In this case medical evidence suggested that had she attended Hospital twenty four hours than 24 hours. earlier then the outcome may have been different. Action Taken A Root Cause Analysis was undertaken following Ms Bannister’s death and action was taken with regard to record keeping and observation of patients. Additionally, a review of the discharge information leaflet was undertaken; however we fully acknowledge that the review did not adequately address the risks that have been identified during the inquest. We have therefore revised the leaflet to include clear instruction to patients in line with the Coroner’s recommendations. The leaflet has been approved by the Endoscopy Steering Group. shared with all staff and is now in use. The leaflet is enclosed. Finally, may we take this opportunity to offer our unreserved apologies to Ms Bannister’s family for the inadequate discharge information provided to Ms Bannister following the ERCP procedure, along with our sincere condolences for their lOSS. Yours sincerely Medica Director
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