Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0078, written 5 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Mar 2015 |
|---|---|
| Reference | 2015-0078 |
| Deceased | Michael Pollard |
| Coroner | Lydia Brown |
| Coroner area | Leicester (City & South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 41. Mr. John Adler Chief Executive University Hospitals of Leicester NHS Trust 1 | CORONER | am Lydia Brown, assistant coroner, for the coroner area of Leicester City and Leicestershire South 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 30" June 2014 | commenced an investigation into the death of Michael Andrew Pollard, age 49. The investigation concluded at the end of the inquest on 5" March 2015. The conclusion of the inquest was Michael Pollard developed a duodenal ulcer from the repeat prescriptions of naproxen, provided by his general practitioners to give pain relief from osteoarthritic knee pain. NICE guidelines were not followed to also prescribe a Proton Pump Inhibitor to protect against gastric erosion. He collapsed at home on 23 June and was admitted via ambulance to the Emergency Department at Leicester Royal Infirmary, where an upper gastro-intestinal bleed was diagnosed and the protocol response commenced. Due to delays in escalation to senior colleagues, no early involvement of Intensive care and inadequate resuscitation with blood products, Michael became unresponsive before an endoscopy was arranged and died from massive haemorrhage several hours later on 24 June 2014. Cause of death ja Massive upper gastro-intestinal haemorrhage 1b Bleeding chronic duodenal ulcer 1c Non-steroidal anti inflammatory drug treatment for knee pain 4 | CIRCUMSTANCES OF THE DEATH See above 5 | 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. — During the night that Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date, and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant. | was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future. In my opinion the following matters need to be considered (1) The on call rota must be up to date, accessible by both switchboard and those Clinicians who need access to it (2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota (3) 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 1 May 2015. 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons | sé brother of the deceased | Holly Lodge Court Care Home one SP | 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 | [DATE] 'SIGNED| ER] ¢ Mod Dos nN
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.
University Hospitals of Leicester NHS) NHS Trust Direct Line: Fax No EMai: — Your Ref: = y Our Ref: Si 12 May 2015 Mrs C Mason HM Coroner The Coroner's Court, Town Hall, Town Hall Square, Leicester LE1 9BG Dear Mrs Mason Re Michael Andrew Pollard Thank you for the Regulation 28 report sent to us on 5 March 2015 by your Assistant Coroner. | note that the matters of concern relate to the on-call rota held by switchboard to enable contact to be made to the on-call GI consultant. You felt that two points needed to be considered:- 41. That the on-call rota must be up to date, accessible by both switchboard and those clinicians who need to access it, and 2. Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota. | am now in a position to respond. All Clinical Specialties arrange their on-call rotas in advance and report these rotas to Switchboard. Although some specialities are able use a web-based system this is still largely a paper-based system at present and Switchboard transcribe this information, 24 hours in advance of it being needed, to produce a daily on-call rota for the entire Trust. As you will appreciate it can sometimes be necessary to make changes to the on- call arrangements whether because of sickness or for other personal reasons. In these cases the responsibility for notifying switchboard of the change remains with the doctor who has arranged for his/her period of on-call to be covered by a colleague. Thereafter it is the responsibility of Switchboard staff to update the information so that it is captured in the daily on-call rota they prepare. This rota University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website; www. leicesterhospitals.nhs.net Chairman: Mr Karamjit Singh Chief Executive: Mr John Adler details all on-call staff across the Trust for the day in question and contains contact details for on-call staff. Clinicians who need to access the on-call information can do so via Switchboard. From this you will see that we have a central single point for amending the on-call rota and a process both for keeping it up to date and also accessible to clinicians. Generally this system works well but unfortunately did not do so on this occasion. | understand that prior to the conclusion of this inquest your Assistant Coroner was provided with a copy of the Trust's Investigation Report into Michael's death and which indicates that regrettably there was a delay in identifying the correct on-call gastroenterologist as the on-call rota had not been properly updated. As indicated in the Investigation Report there is to be a review of the system by the Switchboard Management Team. These matters will be reported to our Adverse Events Committee which requires assurance that actions identified in such Trust Reports are followed up and | can confirm that this will occur here. As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated. The Trust is in the process of procuring a trust-wide web-based system to manage our on-call rotas. Our Chief Medical Information Officer expects to have this system available for use throughout the Trust by the end of this calendar year. Once adopted this system should strengthen and improve our processes with information being uploaded in real-time and visible to clinicians. | hope that this response assures you that we take these matters seriously. If you wish for any further information please do write to me again. Kind regards. Yours sincerely John Adler Chief Executive University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www. leicesterhospitals.nhs.net Chairman: Mr Karamjit Singh Chief Executive: Mr John Adler
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