Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0531, written 10 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Dec 2014 |
|---|---|
| Reference | 2014-0531 |
| Deceased | Patricia Edge |
| Coroner | Simon Allen |
| Coroner area | Manchester (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 THIS REPORT IS BEING SENT TO: 1. The Royal Bolton Hospital NHS Foundation Trust 2 a c/o Mark Reynolds Solicitors 3. Chief Coroner CORONER I am Simon David Allen Jones H M Assistant Coroner, for the Coroner Area of Manchester West 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. INVESTIGATION and INQUEST On 29" July 2014 I commenced an investigation into the death of Patricia Edge, 66. The investigation concluded at the end of the inquest on 3 December 2014. The conclusion of the inquest was that the cause of death was:- 1a)Ischaemic bowel 1b) Bowel obstruction 1c) Advanced colorectal carcinoma II) Paracetamol liver toxicity The conclusion was that Patricia Edge was diagnosed with diverticulitis following admission to the Royal Bolton Hospital on the 10th May 2014 with a history of abdominal pain and diarrhoea since February 2014. A colonoscopy was planned but she was readmitted on the 14th July 2014 when she was prescribed an excessive dose of paracetamol which was not corrected until the 19th July 2014. A biopsy taken on the 28th June 2014 had resulted in a report dated 2nd July 2014 confirming the presence of bowel cancer. A CT scan on the 16th July 2014 showed the cancer had spread and the bowel was obstructed. The obstruction led to the bowel becoming ischaemic - a rare condition - and her condition deteriorated and she died at the Royal Bolton Hospital on the 20th July 2014. CIRCUMSTANCES OF THE DEATH Patricia Edge died in Royal Bolton Hospital of bowel cancer, but an excessive dose of paracetamol dispensed between 14” and 19" July 2014 contributed to her death. 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 circumstances — including training of staff and Trust procedures - in which a patient could be prescribed and dispensed an excessive dose of paracetamol on the 14" July 2014. (2) The apparent lack of any review of the paracetamol dose between 14" and 19" July 2014. (3) The apparent failure to carry out blood tests between 14" and 19" July, which would have revealed/confirmed the possibility of the dose of paracetamol being excessive, again considering issues of training and procedures. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I 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 7" February 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetabie for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons a (daughter of Patrica Edge). 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. Simon Davic_Ali ne 7 10/12/2014
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.
Tel No: 01204 390808 Cure Bolton Your Re NHS Foundation Trust Email: Please ask for NEPA) 2 February 2015 Private & Confidential Mr Simon Jones H M Assistant Coroner HM Coroner’s Court (Greater Manchester West District) Paderborn House Howell Croft North BOLTON BL1 1QY Dear Mr Jones | am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the inquest into the death of Patricia Edge, who sadly died on 20 July 2014. | am now in a position to respond to your concerns outlined below as follows:- Issue 1 — The circumstances — including training of staff and Trust procedures in which a patient could be prescribed and dispensed an excessive dose of paracetamol on the 14 July 2014. Issue 2 — The apparent lack of any review of the paracetamol dose between 14 and 19 July 2014. Issue 3 — The apparent failure to carry out blood tests between 14 and 19 July which would have revealed/confirmed the possibility of the dose of paracetamol being excessive, again considering issues of training and procedures. Actions taken: Following an investigation by senior managers into your concerns, the Trust has identified that across the organisation there have been variations in respect of Paracetamol prescribing. The Medical Devices Committee and the Medications Safety Group have worked closely to address these issues and the process for prescribing Paracetamol has been thoroughly reviewed. As a result the Trust has now has revised its practice and this improvement will ensure that where patients are prescribed Paracetamol there will be regular monitoring by the clinical team responsible for the patient. The attached SBAR (Situation, Background, Assessment and Recommendations) slide details the seven actions taken by the Trust and addresses the three concerns that you have raised. An SBAR is a quality improvement tool which has been adopted by the Trust and is being used as a mechanism to communicate critical information to relevant staff and foster a culture of patient safety. The SBAR has been distributed to all medical staff across the organisation and to wards and services where Paracetamol is used. The message has been disseminated to staff through the PINUP (Policy, Information, role of NHSLA and Understanding Processes) Newsletter and through the Staff Bulletin issued on 30 January 2015. In addition, the Medicines Management e-learning module has been amended to reflect the improved process and ensure the message is continually circulated to clinical staff. We are confident that the Trust has taken all reasonably practicable steps to improve the system of prescribing of Paracetamol in order to address your concerns and | do hope that my response has provided you with the assurance that you and the family are looking for. If you need any further information, or if | can be of any further assistance please do not hesitate to contact me. Yours sincerely Dr Jackie Bene Chief Executive
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