Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0519, written 26 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 | 26 Nov 2014 |
|---|---|
| Reference | 2014-0519 |
| Deceased | Marjorie Ellery |
| Coroner | Simon Wickens |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Frimley Health 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Death of Marjory Rosina ELLERY A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: The Chief Executive of Frimley Park Hospital 1 CORONER Simon Wickens HM Assistant Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into Marjory Rosina Ellery’s death was opened on the 26th February 2013 was resumed on 12th of November 2014. The Coroner found the cause of death was: 1a – Anaphylactic shock (clopidogrel and dalteparin related) 2 – Ischaemic heart disease due to coronary artery atheroma The Coroner returned a narrative conclusion: Marjorie Rosina Ellery died at 05.40 hours on the 16th January 2014 at Frimley Park Hospital following the administration of medication to which she was known to be allergic and which caused anaphylactic shock and subsequently death. 4 CIRCUMSTANCES OF THE DEATH On 15th January 2014 Marjorie Ellery was taken by ambulance to Frimley Park Hospital following her experiencing chest pains. She was seen by a staff nurse and her allergies to medications were noted and placed on red RT4423 1 wristbands. Mrs Ellery was examined by an A&E doctor who prescribed Acute Coronary Syndrome Medications (ACS) ‐ two of which Mrs Ellery was known to have an allergic reaction to. One of these medications (Clopigdogrel) had been prescribed despite a known allergic reaction in late 2013 when ACS Medications were administered. This was without problem. Dalteparin had not been prescribed at this time and an alternative was used. The Dr handed over the administration of the medications to a staff nurse. The staff nurse told Mrs Ellery she would be given three medications to which she was allergic but which she had been given in the past. The names of the medications were not given to Mrs Ellery and she had only received two of the three in the past. Soon after taking the medication Mrs Ellery became faint with signs of a rash. She suffered an anaphylactic shock and subsequently died on the 16th January 2014. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a number matters that gave rise to a concern that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are as follows. – 1. Action is required to ensure that medication is not administered to a patient to which they are known to have an allergy without advice being sought from a doctor of appropriate designated seniority or experience. 2. Action is required to ensure that consent obtained from a patient as to the administration of medication to which there is a known allergy is informed consent. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the Chief Executive of Frimley Park Hospital has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. RT4423 2 Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the Interested Persons in the Inquest and the Chief Coroner. 9 Signed: Simon Wickens DATED this 26th day of November 2014. RT4423 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.
Frimley Health NHS Foundation Frimley Park Hospital Portsmouth Road Frimley Ref: i Camberley Surrey GU16 7UJ 2g 8" January 2015 Tel: Mr S Wickens HM Coroner HM Coroner’s Court Station Approach WOKING Surrey GU22 7AP Dear Mr Wickens RE: Mrs Marjorie ELLERY (Deceased) Thank you for your letter dated 27" November 2014 and the attached Regulation 28 Prevention of Future Deaths Report relating to the above named. Thank you for the agreed extension of 2 weeks due to the Christmas and New Year holidays. The Regulation 28 highlighted 2 areas of concern: e Action is required to ensure that medication is not administered to a patient to which they are known to have an allergy without advice being sought from a doctor of appropriate designated seniority or experience e Action is required to ensure that informed consent is obtained from a patient as to the administration of medication to which there is a known allergy We have reviewed the concerns raised following the inquest into Mrs Ellery’s death and have outlined below the Trust’s position in relation to the 2 points raised. The Trust has made the decision that any patient who requires a medication that they are known to have an allergy to, the decision to give this medication must be authorised by a registrar or above and documented in the notes. A discussion with the patient must be undertaken by the medical team and consent gained from the patient (if able) or discussed with a relative where applicable and documented in the medical notes and signed by the patient. The patient’s red wrist band which denotes an allergy must include the name of the drug and the reaction but no more than 2 drugs recorded on one wrist band. These significant changes in practice have been presented to, and agreed at, both the Trust Quality & Safety Committee and Medication Safety Committee. The guidance on allergies was included in the Trust's Record Keeping Guideline but as a result of these changes in practice a new policy has been developed on Frimley Health NHS Foundation Trust the Management of Allergies. This is currently out for comment and will be ratified at the Medication Safety Committee on the 18" February 2015. These changes in practice have already been communicated to the medical teams by the Medical Director and the Lead nurses at a variety of Trust Forums and committees. The monthly Patient Safety Training for all nursing staff has been reviewed and amended to include training on the management of allergies. In addition, the Trust is in the process of reviewing its current drug assessment competency for nursing staff to include the changes in practice as part of the theory and practical test. The Trust is committed to patient safety and takes cases such as this very seriously and hope this is demonstrated in our response to the concerns you have raised. However, if | can be of any further assistance, please do not hesitate in contacting me. Yours sincerely Andrew Morris Chief Executive
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