Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0509, written 24 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 | 24 Nov 2014 |
|---|---|
| Reference | 2014-0509 |
| Deceased | William Jackson |
| Coroner | D LI Roberts |
| Coroner area | Cumbria (North & West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RE: William Walton Jackson Deceased THIS REPORT IS BEING SENT TO: 1. Sir Leonard R.Fenwick.CBE. Chief Executive of Newcastle Foundation NHS Trust CORONER | am D.LI. Roberts, Senior Coroner, for the coroner area of North & West Cumbria 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 2.12.2013 | commenced an investigation into the death of William Walter Jackson Aged 78. The investigation concluded at the end of the inquest on 6.11.14 The conclusion of the inquest was 1a) Haemothorax b) Ruptural descending thoracic aortic aneurysm. Conclusion: Natural Causes 4 CIRCUMSTANCES OF THE DEATH In the spring of 2013 the deceased was diagnosed with severe aortic regurgitation, a large ascending aortic aneurysm and severely impaired left ventricular function. His descending aorta was also aneurysmal. In the 26" June 2013 he underwent an operation at the Freeman Hospital to replace the aortic valve and the ascending aorta. The plan was to review the descending aorta in Spring 2014. By the Bank Holiday Monday of the 26" August 2013 he had become unwell. At the Cumberland Infirmary on the 277 August a CT Scan of his aorta was performed. This scan revealed there was haemorrhage in the descending aorta. The reporting radiologist did not perceive the increase in thickness of the aortic wall and intramural haematoma evidencing, at last stage, a contained rupture. This lack of appreciation of acute aortic pathology resulted in an inaccurate report which was relied on by subsequent clinicians. He left the hospital on the 27" but was admitted as an inpatient on the 30" August and died on the 4" September 2013. The true nature of his presenting problem was not diagnosed by his treating clinicians, but had it been, on the balance of probability it is unlikely that anything other than conservative treatment would have been proposed. i 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) The CIC records showed that an A&E doctor had spoken to a Specialist Cardio Thoracic Registrar at the Freeman Hospital. Inquiries of the Freeman showed that there was no record/recollection of this contact. (2) | understand there is no system at the Freeman to formally record sudden interactions. This means no traceable record and no means by which the Freeman doctor could be identified let alone recall the advice given. (3) The advice appears to have been given without the Freeman doctor actually seeing the CT Scan. Has the images been reviewed it is possible that the true state of the deceased’s health would have been ascertained. (4) Independent of the issue of an enquiry being able to establish what advice was given at the time; there is a risk that the way such advice appears to have been given could place patients lives at risk. ACTION SHOULD BE TAKEN 2 In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE 4 You are under a duty to respond to this report within 56 days of the date of this report, namely 20" January 2015 hence. |, 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. 1 2. MEEEB- Scott Duff & Co. Solicitors 3. Mrs Ann Farrar — Chief Executive NCUH NHS Trust 4. Beachcroft Solicitors | am also under a duty to send the Chief Coroner a copy of your response. Also to 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. 24.11.14 D.LI. HM_-Senior Coroner aed G Sop ets
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 Newcastle upon Tyne Hospitals INHS| NHS Foundation Trust Headquarters Freeman Hospital High Heaton Newcastle upon Tyne Tel: 23rd January 2015 Fax: www.newcastle-hospitals.nhs.uk D.LI.Roberts H.M. Senior Coroner Fairfield Station Road Cockermouth Cumbria CA13 9PT Dear Sir I refer to your letter dated 24 November 2014 regarding William Walton Jackson (Deceased). I understand that your concerns relate to the recording of communication between the Cardiothoracic Specialist Registrar at Freeman Hospital and staff at Cumberland Infirmary. I understand that the Cumberland Infirmary Accident & Emergency Department records do not indicate the exact time that the request for advice was made to the Specialj gistrar at Freeman Hospital. The Registrar on the night shift SS not recollect the patient but advises it is his usual practice to review the diagnostic scans/images if they are available before offering an opinion. It is documented that Mr Jackson arrived at the Accident & Emergency Department at 13.30 hours. The arrival time and the timing of the CT scan undertaken at Cumberland Infirmary does serve to suggest it is most likely that an opinion was sought during the day shift. During this period the Specialist Registrar was a locum, NE and it has not been possible to make contact with him. It has therefore not been possible to confirm if he gave the advice or indeed whether or not he viewed the scans himself before he provided that advice. It is however usual practice throughout Cardiothoracic Surgery to review the scans themselves, if available, before providing advice in such cases. Scans sent from other hospitals are received via the Radiology Picture Archiving and Communication System (a computerised digital infrastructure), but only remain on the system for a finite period unless a request is made to be permanently archived. A record of receipt of the scans is created automatically on the system, however this original record is over written by the system if a subsequent request is made, as occurred in this case. It is therefore not possible to confirm whether or not the scans had been received at the Freeman Hospital at the time the opinion was provided. In response to the Regulation 28 letter and as part of ongoing quality improvements the Regional Cardiothoracic Centre at the Freeman Hospital has addressed the following actions: Kingsley W. Smith OBE, Chairman Sir Leonard Fenwick CBE, Chief Executive (i) Actions already taken: e An electronic system is now in place within Cardiothoracic Surgery to record details of advice given when medical opinion is sought by a_ healthcare professional in another hospital. e The Cardiothoracic Surgical Team is fully aware of the need to ensure consistency when using this system on receiving requests for a medical opinion from outside of the Trust and where there is no opportunity to make a documented statement in the medical record. (ii) Further planned actions: ¢ The importance of using the electronic system to record the details of opinions sought, information available on the system has been be included in the induction programme of newly recruited staff including trainees who are on rotation from other parts of the NHS. e The current system is being further developed throughout the Newcastle Hospitals to prompt recording of key items including information regarding radiological images viewed at the time of providing an opinion. I do hope this commitment and set of actions taken shall provide the assurances sought. Please do not hesitate to contact me if you require any clarification. Yours‘Sincerely Sir Leonard Fenwick CBE Chief Executive
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