Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0547, written 19 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 | 19 Dec 2014 |
|---|---|
| Reference | 2014-0547 |
| Deceased | Pauline Edwards |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Jeremy Hunt MP Secretary of State for Health, Richmond House, 79, Whitehall, London. SW1A 2NS 1 | CORONER | am Dr Fiona Wilcox, Senior Coroner, for the coroner area of Inner West London 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 21°' December 2010, | commenced an investigation into the death of Ms Pauline Verona Edwards, aged 49 years. The investigation concluded at the end of the inquest on 27" October 2014. The conclusion of the inquest was: Medical Cause of Death 1 (a) Hypoxic Ischaemic Encephalopathy (b) Cardiorespiratory Arrest (c) Operation under general anaesthetic for Benign Ovarian Cyst. How, when and where and in what circumstances the deceased came by her death: Ms Pauline Edwards, a healthy 49 year old female patient, died at St Georges Hospital, Tooting, London at 17:20 on the 15" December 2010. After successfully undergoing an operation for the removal of an ovarian cyst, the patient had difficulty in waking up, suffered a laryngospasm leading to hypoxia and a cardiac arrest which resulted in the patient’s death. Conclusion of the Jury as to the death On the 10" of December 2010, Ms Edwards was admitted for the removal of an ovarian cyst. The surgery finished C. 18:36. Prior to 19:00 the patient coughed and was extubated at this point. Shortly after 19:00, the responsible anaesthetist asked the ODP to get Naloxone. He failed to find it in the adjacent anaesthetic room and decided to fetch it form recovery, some minutes away, without first communicating this to the responsible anaesthetist. We find this a failure on the part of the ODP in serving the anaesthetist. Around 19:05, the patient stopped breathing due to a laryngospasm. The responsible anaesthetist failed to diagnose the cause of the respiration difficulties. We find this to be a serious failure. The laryngospasm was diagnosed when a junior colleague entered the operating theatre at approximately 19:16, monitor time, by which time irreversible brain damage was likely to have occurred. The responsible anaesthetist did not call for help using standard hospital protocol. This was a contributing factor to the death of the patient. We find this to be a serious failure within the first two minutes. We find the anaesthetist’s continued failure to call for help to be a really serious failure. At or around 19:16 a junior anaesthetist entered the operating theatre and the patient was re-intubated by the responsible anaesthetist. The tube was wrongly inserted into the oesophagus. The fact that the responsible anaesthetist did not recognise that the tube was in the wrong place, despite no endtidal CO2 readings constitutes a serious failure. The patient subsequently suffered cardiac arrest due to prolonged hypoxia. The patient was sufficiently oxygenated at 19:30 after 24 minutes of insufficient oxygenation. The damage to her brain and other organs was by then irreversible and caused her death on 15" December 2010 at 17:20. We find that throughout these events , communication among the team members within the hospital was in relation to the unplanned over run to be inadequate but that this was not a direct cause of the death. CIRCUMSTANCES OF THE DEATH It was clear from the evidence taken during the inquest that the responsible anaesthetist, who had trained in Italy, had clearly insufficient experience to deal with the most common anaesthetic emergency, and that had reacted appropriately in recognising and treating the laryngospasm when it first developed this death would probably not have occurred. On paper, this doctor was supposed to be qualified to the level of a consultant, whilst in reality she had probably had little practical training, especially in the management of anaesthetic emergencies. She had been employed as a clinical fellow, and should have been qualified to act alone. EU Regulations require the UK to recognise EU qualifications of doctors even though their training may be well below that of an equivalently graded doctor in the UK. 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) That UK Hospitals are forced by EU law to accept the qualifications of EU trained doctors even though such doctors may not have the same training and experience as an equivalently graded doctor in the UK (2) That UK Hospitals are unaware of this and thus allow such doctors to practice unsupervised and thus put patients’ lives at increased risk. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. | would commend the training and supervision programme put in place art St George’s Hospital to try and mitigate such risks following this death, and suggest that the DOH may wish to consider reviewing the St George’s programme as an example of good practice to be shared by the NHS. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 430 February 2014. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : Clinical Director Theatres and Anaesthetists St George’s Hospital Blackshaw Road London SW17 0QT Anaesthetics Senior Clinical Fellow St George’s Hospital Blackshaw Road London SW17 0QT Advanced Theatre Practitioner St George’s Hospital Blackshaw Raod London SW17 0QT | have also sent it to the following persons or organisations who may find it useful or of interest: pe OCCE General Medical Council Regent's Place 350 Euston Road London NW1 3JN lam 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. 19™ December 2014. Dr Fiona Wilcox, HM Senior Coroner, Inner West London, Westminster Coroner’s Court, 65, Horseferry Road, London. SW1P 2ED.
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.
Parliamentary under Secretary of State for Health
From Dr Dan Poulter MP
Richmond House
79 Whitehall
London
SW1A 2NS
24th February 2015
Dr F Wilcox
HM Senior Coroner
Westminster Coroner’s Court
65 Horseferry Road
London
SW1P 2ED
Dear Dr Wilcox,
Thank you for your letter following the inquest into the death of Pauline Edwards. I was very
sorry to learn of Ms Edwards’s death and wish to extend my sincere condolences to her
family.
The inquest concluded that Ms Edwards died as a result of an operation under general
anaesthetic for benign ovarian cyst, hypoxic ischaemic encephalopathy and cardiorespiratory
arrest.
You outline the events surrounding the operation and explain several serious failings on the
part of the responsible anaesthetist that led to a prolonged period of hypoxia resulting in
cardiac arrest and death.
You report that the responsible anaesthetist had trained in Italy and, from evidence at the
inquest, clearly had insufficient experience to deal with the most common anaesthetic
emergency even though she was supposed to be qualified to the equivalent level of
consultant. You point out that EU Regulations require the UK to recognise EU qualifications
of doctors even though the actual training may be well below that of an equivalently
qualified doctor in the UK.
You had particular concerns:
That UK hospitals are forced by law to accept the qualifications of EU trained doctors
even though these doctors may not have the same training and experience as doctors in
the UK.
That UK hospitals are unaware of this and so allow such doctors to practise
unsupervised and so put patients’ lives at risk.
You also commend a training and supervision programme that St George’s hospital has put
in place following this death and ask that the Department considers sharing this example of
good practice within the wider NHS.
To address your concern about the equivalency of non-UK medical training and standards, I
would like to first draw your attention to the Mutual Recognition of Professional
Qualifications Directive (MRPQ).
This Directive, agreed in 2005 and transposed into UK law in 2007, allows professionals to
have their qualifications, obtained in one Member State, recognised in another and thus
allows them to be employed anywhere within the Single Market irrespective of where they
have trained. The Directive applies to the European Economic Area (EEA), which includes
EU Member States along with Norway, Iceland and Liechtenstein.
The system of automatic recognition under this Directive applies to seven professions;
doctors, dentists, general care nurses, midwives, pharmacists, veterinary surgeons and
architects. For these professions there are harmonised minimum training requirements and
Member States are obliged automatically to recognise qualifications which meet these
criteria.
In addition, Article 25 of the MRPQ Directive requires that any admission to medical
specialty training is contingent upon completion of the harmonised basic medical training
requirements under the Directive. In order for an individual to benefit from automatic
recognition of a specialty qualification the specialty courses must be listed in Annex 5 of the
Directive under both the home and host Member State. In order to be listed under Annex 5
the specialty training must comply with the minimum period of training, which is set out in
Annex 5 point 5.1.3 of the Directive, for each listed specialty.
However, the Department is aware that the General Medical Council (GMC) has some
concerns around the comparability of curriculum between some of the UK specialties and
specialties in other Member States listed under Annex 5. Subsequently officials at the
Department of Health are working with the GMC to strengthen the processes around
confirming that medical specialties have equivalent curriculum content to ensure that EU
doctors working in the UK are of a suitable standard to maintain patient safety.
The Department is also working with the GMC to make sure there is a robust process for
considering new additions to the medical specialties listed in Annex 5 of the Directive before
the UK agrees to list its own comparable specialty.
Regarding the training and supervision programme at St George’s hospital, as part of the
application process for registration, clinical staff from within the EU have their qualifications
verified by the General Medical Council. These clinical staff are then encouraged to carry
out an “observership” placement, prior to applying for jobs, to familiarise themselves with
the NHS.
When the St George’s Healthcare NHS Trust receives a job application, the applicant’s
written communication skills are assessed from their application form and their verbal
communication skills are assessed at interview. An applicant’s level of training, experience
and knowledge is assessed at interview through clinical scenario assessments. References
and letters detailing employment are sought from relevant overseas employers to confirm an
applicant’s experience.
Staff appointed then attend a course run by the simulation team at St George’s Hospital
which aids their transition to the UK and to the NHS.
Health Education England (HEE) is the appropriate body to comment on the training and
supervision programme run by St. George’s hospital. They consider this induction
programme, which features increased initial supervision and mandatory sign-off for non-UK
trained staff before they can go onto any rota appears thorough and could be disseminated as
an example of good practice. However, whilst HEE provides national, strategic leadership on
education and training that is responsive to patient’s changing needs, primary responsibility
for induction arrangements for clinical staff rests with individual employers.
I hope that this response is helpful and I am grateful to you for bringing the circumstances of
Ms Edwards’s death to my attention.
Best wishes,
DR DAN POULTER
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