Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0554, written 24 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 | 24 Dec 2014 |
|---|---|
| Reference | 2014-0554 |
| Deceased | David Mountain |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Queen Elizabeth Hospital, King's Lynn, NHS Foundation 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1} REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Queen Elizabeth Hospital Gayton Road King's Lynn Norfolk CORONER | am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK 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. INVESTIGATION and INQUEST On 26 June 2014 I commenced an investigation into the death of DAVID JOHN MOUNTAIN, Aged 71 years. The investigation concluded at the end of the inquest on 22 December 2014. The conclusion of the inquest was medical cause of death: 1a) Haemopericardium and Pericarditis b) Myocardial Perforation c) Pacemaker Insertion for complete Heart Block II Aortic Stenosis. Conclusion: Recognised risk of a necessary medical procedure. ‘ CIRCUMSTANCES OF THE DEATH Mr Mountain was found incidentally to have a slow heart rate. He was referred to Queen Elizabeth Hospital (QEH) on 13 June 2014. Following investigation this was confirmed and as he was found to be at high risk of developing heart failure, he was admitted to Cardiology Ward and recommended for permanent pacemaker implant. Risks were explained to him. He was transferred to Papworth Hospital on 20 June 2014. Procedure performed without any recognised complications. Mr Mountain was reviewed following procedure on 21 June 2014 and chest x ray raised no concerns. Mr Mountain was discharged. On way home he developed chest pain and was taken directly to QEH. Started on antibiotics for sepsis of unknown source. He deteriorated and died on 23 June 2014. ‘ 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. — Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr Mountain developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiagram was not performed until afternoon of 23 June 2014. The results, which showed a mild to moderate bleed around the heart, were not available until after Mr Mountain's death. 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 27 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: (wife) Chief Executive, Papworth Hospital |. am also under a duly 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. 24 December 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.
The Queen Elizabeth Hospital NHS) King’s Lynn NHS Foundation Trust The Queen Elizabeth Hospital Gayton Road Kings Lynn Norfolk PE30 4€T 16 rep 2 www.gehkl.nhs.uk B Chief Executive Tel: Date: 12" February 2015 Fax: Minicom: Your ref: Regulation 28 Report Ms. J Lake LL.M E-mail: Senior Coroner for Norfolk 69 —- 75 Thorpe Road Norwich Norfolk NR1 1UA Dear Ms Lake, | am responding to the Regulation 28 report dated the 24" December 2014 which was received by the Trust on the 29" December 2014 in relation to the on-going investigation into the death of Mr David John Mountain. I can confirm that the organisation has undertaken a detailed analysis of the circumstances of Mr Mountain’s death. All clinicians invoived in his care have been spoken to and a number of immediate changes have been made: 1. The Cardiology team are implementing clear guidance for all doctors within the Emergency Department, the Medical Assessment Unit and the Surgical Assessment Unit which highlights the key clinical areas which should be investigated if a patient is admitted following recent permanent pacemaker insertion. This guidance will be shared with the relevant senior clinical decision makers and in place by the end of February 2015. 2. In the event that any abnormal results are identified, the cardiac technician now directly contacts the referring clinical team in hours (or the on-call Medical Registrar out of hours) thus enabling a prompt clinical response to be made. Alongside this, we are moving to an electronic reporting system for all test results including echocardiography. Scoping of this major IT project has commenced and we anticipate that it will be in place by the end of 2015. This will allow doctors access to reports immediately when they are entered onto the system and will eliminate the need to transfer a paper copy report from one area of the hospital to another. 3. Cardiology Consultants are now routinely present on site on a Saturday and Sunday to review cardiology patients and provide advice to all clinical teams within the Hospital. Chair: Edward Libbey Interim Chief Executive: Manjit Obhrai Patron: Her Majesty The Queen 13 February 2015 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust This is an important part of the Trust’s move to 7 day services and ensures that senior decision making can occur every day of the week. The planned recruitment in the next six months of further joint appointments (QEH/ Papworth) will make 7 day cardiology services sustainable for the future at the Queen Elizabeth Hospital. | would be grateful if you could pass on my condolences to Mr Mountain’s family and my apologies for any additional distress which has been caused to them at this difficult time. | hope that this information is sufficient to answer your outstanding concerns but if you have any further queries, please do not hesitate to contact me. Yours sincerely Dorothy Hosein Chief Executive Page 2 of 2
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