Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0515, written 25 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 | 25 Nov 2014 |
|---|---|
| Reference | 2014-0515 |
| Deceased | Stephen Mayoll |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Portsmouth Hospitals University NHS 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.
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 Chief Executive, Portsmouth Hospitals NHS Trust 1 | CORONER | am David Clark Horsley, senior coroner, for the coroner area of Portsmouth and South East Hampshire. 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 28" June 2013 | commenced an investigation into the death of Stephen Anthony Mayoll, aged 44. The investigation concluded at the end of the inquest on 19° November 2014. The conclusion of the inquest was: Narrative Conclusion: 1- On10" June 2013 Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury for which he received treatment as an out-patient at Queen Alexandra Hospital, Portsmouth, between 11" and 20" June 2013. 2 On21* June 2013 he became very unwell at home and was taken by ambulance to Queen Alexandra Hospital where he died at 03.20 hours on 22™ June 2013. 3- He died as a result of complications of his injury and its treatment at the hospital between 11" and 20" June 2013, namely a pulmonary thromboembolism arising from a deep vein thrombosis in his right lower leg. Mr Mayoll did not fulfil the criteria then in force at the hospital for the use of anti-coagulation therapy in respect of Achilles tendon injury patients and in consequence did not receive such therapy which, on the balance of probabilities, would have reduced the risk of those complications arising. 4 | CIRCUMSTANCES OF THE DEATH The circumstances of Mr Mayoll's death are set out in Paragraph 3 above. 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. — 1- Out-patients with similar injuries to Mr Mayoll's returning to the fracture clinic at Queen Alexandra Hospital experiencing problems with their treatment or for periodic review are not subject to re-assessment under the hospital's DVT assessment policy. If they were, there would be less risk of their developing DVT's during the course of their treatment. 2- Evidence was given at the Inquest highlighting the delay in typing fracture clinic doctors' notes meaning that they would not always be available if an out-patient returned to the clinic and improved methods of making the notes available sooner to the clinic (e.g. by use of voice recognition IT) would obviate this problem. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 20" 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: 4- a 2- RCN Legal Services [A | 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. 25" November 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.
Portsmouth Hospitals NHS Trust Trust Headquarters F Level, Queen Alexandra Hospital Ursula Ward MSc MA Southwick a Road ti osham li PORTSMOUTH, PO6 3LY Tel; PRIVATE & CONFIDENTIAL Mr D C Horsley LLB, Solicitor Her Majesty's Coroner for Portsmouth and South East Hampshire Coroner's Officer The Guildhall Guildhall Square Portsmouth PO1 2AB 19 January 2014 Our ref: (Please quote our ref in all correspondence) Dear Mr Horsley | refer to your Regulation 28 Report of 25 November 2014 which the Trust has considered carefully. | am pleased to be able to set out below the actions which we are Intending to take to ensure that everything possible is done to prevent future cases such as Mr Mayoll's. 1. Patients who retum to the fracture clinic with lower limb injuries as “in trouble” or for routine review, will have a reassessment of thelr risk factors for VTE each time they attend, the result of which will be considered by the doctor reviewing them. This will be documented via the normal route on a plaster room “in trouble” form which is currently being updated and will include the recommendations which arose from the Inquest relating to VTE assessment. 2a. We will ensure that the review by the plaster technicians will be recorded, signed and correctly dated and then scanned and saved by “Windip" (an electronic storage system) so that if the patient returns again, the information is available for the health care professional to view and follow the decision making and treatment plan from the previous visit, The scanner required for this to take place is currently on order. 2b. An_“in trouble” patient reviewed by the Consultant will have the notes dictated that day and then typed up by the Orthopaedic secretaries and the alm is for them to be typed within 24- hours. We are exploring IT solutions as well but thls Is the interim solution. The current EPRO system (a digital dictation system) involves the notes being typed up by agency staff and, possibly, in the future, outside agencies and It is anticipated that the normal typing turnaround will be at 48-hours by the end of March which is still not quick enough to ensure that information Is available for a Consultant reviewing a returning patient. However, there Is the abllity through EPRO to gain access to the tapes but the Consultants can listen to the recording If the typed notes are not available. This is being fed back at the next consultants’ meeting, by way of reminder. | hope that the above plan addresses your concerns but of course please contact me again if you require any further clarification or information. Yours sincerely Ursula Ward MSc MA Chief Executive
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