Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0017, written 21 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2015 |
|---|---|
| Reference | 2015-0017 |
| Deceased | Philip Smith |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive, Huddersfield Royal Infirmary
2. Chief Coroner
3.
1
CORONER
I am Mary Burke, Assistant Coroner, for the coroner area of West Yorkshire (Western)
2
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.
[
3
INVESTIGATION and INQUEST
On 21st March 2014 I commenced an investigation into the death of Phillip Roy Smith, a
64 year old married gentleman. The investigation concluded at the end of the inquest on
10th December 2014. The conclusion of the inquest was that Mr. Smith died as a result
of natural causes. The medical cause of death was established to be due to 1(a)
Duodenal haemorrhage and hypovolaemic shock 1(b) Duodenal infiltration by pancreatic
tumour 1(c) obstructing tumour head of pancreas.
4
CIRCUMSTANCES OF THE DEATH
Phillip Roy Smith had a previous medical history of suffering a myocardial infarction,
following which he underwent coronary artery stenting. On the 24th February 2014 he
was fast tracked by his general practitioner to Huddersfield Royal Infirmary with sudden
onset of jaundice.
His mother and sister had previously both died from pancreatic carcinoma.
Following ultrasound and CT scan imaging a likely diagnosis of pancreatic carcinoma
was made.
An ERCP procedure was subsequently attempted with a view to alleviating Mr. Smith’s
symptoms and at the same time to take a biopsy in order to confirm the likely diagnosis.
Unfortunately the treating clinician was unable to enter the duodenum and therefore the
procedure was stopped.
After further MDT review a decision was taken for Mr. Smith to undergo a
percutanaeous transhepatic cholangiogram, together with insertion of external drain.
This was undertaken on the morning of the 14th March 2014 and proceeded
uneventfully.
Following return to the ward Mr. Smith appeared to be stable, however standard
observations undertaken by nursing staff at around 2045 hours gave rise for concern.
The senior nurse on duty requested observations to be repeated after 30 minutes.
This was implemented and observations returned within normal range. No record was
made of these further observations within Mr. Smith’s medical notes and records.
Shortly thereafter Mr. Smith refused his night-time medication. No note was made of this
within the nursing notes and records.
At approximately 1.00 a.m. in the early hours of the 15th March 2014 Mr. Smith’s
condition appeared to significantly change. He vomited and was experiencing severe
significant pain. Mr. Smith was given Tramadol by one of the nurses on duty but no
record was made of this within the nursing records.
Mr. Smith’s condition was not improving and at approximately 1.30 a.m. nursing staff
requested the attendance of the duty junior house officer, who duly attended and
prescribed fluids and morphine. A blood sample was taken with a view to undertaking
blood gasses.
No note was made by the junior doctor of his attendance and review, nor any record
made of blood gas results.
Shortly thereafter the senior nurse returned to the bedside, at which point the junior
house officer was still in attendance at Mr. Smith’s bedside. She found Mr. Smith on the
floor. No detailed note was made, either by the nurse or doctor, of these events within
the medical notes and records and no record was made of whether this was a witnessed
or unwitnessed fall.
By this stage the senior nurse on duty on the ward was very concerned with regard to
Mr. Smith’s presentation and suggested to the junior doctor that a more senior doctor
review should take place. The junior doctor indicated that he did not need any additional
support.
Mr. Smith’s condition continued to give rise for concern and therefore the senior nurse
requested another nurse to summon a more senior doctor’s attendance.
A senior house officer attended and reviewed Mr. Smith. No note was made by this
doctor, although following review he requested the on-call registrar to attend, who did so
a short time thereafter and noted Mr. Smith had no pulse. CPR was commenced and a
crash team summoned. Mr. Smith’s cardiac output returned. Other tests were
undertaken. It was noted that Mr. Smith’s haemoglobin levels had significantly reduced.
In addition he appeared to be acidotic.
A likely diagnosis of hypovolaemic arrest due to internal bleeding was made, although
sepsis or myocardial infarction were also considered as possible causes for Mr. Smith ‘s
presentation.
In order to confirm the diagnosis Mr. Smith required a CT scan, however Mr. Smith was
not well enough to undergo significant intervention at that stage as his condition
appeared to be very unstable.
Mr. Smith was subsequently transferred to the Intensive Care Unit and was fully
supported, however he remained profoundly unwell with no signs of improvement.
Following discussion with Mr. Smith’s family the decision was taken to stop active
treatment but to ensure he was kept comfortable. Sadly, Mr. Smith’s condition
continued to deteriorate and he died at 11.40 ours on the 15th March 2014 in the
Intensive Care Unit at Huddersfield Royal Infirmary.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise for 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 Standard of Nursing Records
i) On the evening of the 14th March 2014 observation were repeated 30 minutes after
the standard observations were undertaken, but no record was made of these repeat
observations.
ii) Mr. Smith declined his evening medications, but this was not recorded.
iii) Mr. Smith was given Tramadol at around 1.00 a.m. on the morning of the 15th March
but this was not recorded.
iv) Mr. Smith was found laid on the floor beside his bed in the early hours of the
15th March but full details of this event was not made by the nursing staff on duty.
(2) Standard of Doctors’ Records
i) Junior Doctor’s involvement – neither the junior or middle grade doctors who reviewed
Mr. Smith in the early hours of the 15th March 2014 made accurate records of their
review and assessment of Mr. Smith.
ii) Blood gasses assessment was undertaken by the junior doctor on his attendance
around 1.30 a.m. but no record was made of this.
(3) Junior Doctor’s Involvement
i) The senior nurse on duty was concerned of Mr. Smith’s deterioration in the early
hours of the 15th March. At the time of the junior doctor’s attendance she suggested that
a more senior medical review should take place, however the junior doctor indicated that
he did not require any further support in the circumstances notwithstanding Mr. Smith’s
presentation.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18th March 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
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.
9
21st January 2015
Mrs. M. T. Burke, Assistant Coroner
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