Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0082, written 6 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 | 6 Mar 2015 |
|---|---|
| Reference | 2015-0082 |
| Deceased | Connor Turner |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (East) |
| 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.
ANNEX A
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. cm cease Medical Director of the Leeds Teaching Hospitals NHS
rust, Trust Headquarters, St James’s University Hospital, Beckett Street,
Leeds, LS9 7TF
1 | CORONER
| am David Hinchliff, senior coroner, for the coroner area of West Yorkshire (East)
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 28" February 2013 | commenced an investigation into the death of Connor Adrian
Turner, aged three months. The investigation concluded at the end of the inquest on 2
February 2015. The cause of death being :- 1(a) Unascertained and 2. Cystic fibrosis
with previous laparotomy for meconium ileus and previous corrective surgery for
congenital cardiac anomaly. The conclusion of the inquest was :-
Connor Adrian Turner was born on 14 November 2012 with cystic fibrosis and a
congenital heart defect which was repaired on 14" January 2013. Connor subsequently
developed cardiac arrhythmias and a paralysed right hemidiaphragm. Connor also
suffered reflux and possible aspiration. He suffered recurrent chest infections. He was
oxygen dependent and required an oxygen supply via a nasal cannula and cylinder.
The cause of death could not be established.
Between 15:20 and 47:00 hours on 28" February 2013 Connor was not supplied with
oxygen from the cylinder. The poor response to resuscitation, profound acidosis and
high lactate and the severity of the damage sustained are all compatible with a hypoxic
induced cardiorespiratory arrest. Connor’s observations would suggest that he did not
have an acute respiratory infection. {t is unlikely that reflux and aspiration were the
cause of the cardiorespiratory arrest. On the balance of probabilities the cause of death
could not be established but the lack of oxygen was a contributory factor.
Connor Adrian Turner died on 28" February 2013 at The General Infirmary, Leeds at
00:30 hours.
4 | CIRCUMSTANCES OF THE DEATH
Connor Adrian Turner was born on 14 November 2012 with cystic fibrosis and a
meconium ileus. The latter condition was operated on on numerous occasions, the last
of which was on 30" January 2013. Connor had a large ventricular septal defect and
patent ductus arteriosis and an overarching aorta which was repaired on 14" January
2013. This baby also suffered from reflux and aspiration and was fed with a nasogastric
tube. Connor was recovering from Pseudo Bartas syndrome and required oxygen
through a nasal cannula. When he was taken out of the hospital he required a portable
oxygen cylinder.
On 27" February 2013 Connor's parents took him shopping in Leeds city centre. His
oxygen tank was noted to be on and working before they left the hospital. Connor and
his parents were in the Primark store when his mother noticed he had changed colour
and had stopped breathing. Cardio pulmonary resuscitation was carried out.
Paramedics attended. The Paramedic noticed that the oxygen cylinder valve was in the
“off’ position. Connor was then taken by ambulance to The General Infirmary at Leeds,
where despite all efforts his death was confirmed at 0030 hours on 28" February 2013.
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. —
(1) There is no system in place for nursing staff to instruct and train parents and carers
in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder
(2) That parents and carers should be initially supervised in performing this task until
they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the
hospital, albeit temporarily, the patient should not be allowed to leave until an
independent check has been made and all concerned are satisfied that the apparatus is
functioning correctly and that those taking the patient out of hospital are competent to
use the apparatus and that the appropriate reference to this should be made in the case
notes.
6 | 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.
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. |, 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 LOCAL
SAFEGUARDING BOARD (where the deceased was under 18).
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.
9 | 6" March 2015
DAVID HINCHLIFF
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 Leeds Teaching Hospitals INHS NHS Trust Enquiries: Tele Extn: Date: 01 May 2015 Chief Medical Officer Trust Headquarters Mr David Hinchliff enon . Senior Coroner St James's University Hosp tal West Yorkshire (Eastern) Leeds Coroner's Office LS9 7TF 71 Northgate Direct Line: Wakefield Fax: (0113) 2067007 WF1 3BS E-Mail: PA: www leedsth.nhs.uk Dear Mr Hinchliff INQUEST TOUCHING THE DEATH OF CONNOR ADRIAN TURNER (Deceased) | refer to your correspondence of 6th March 2015, received 10th March, regarding the inquest touching the death of Connor Adrian Turner and the Regulation 28 Report to Prevent Future Deaths in respect of this case. We have considered the contents very carefully and the responses to the matters of concern you have raised in the report are detailed below. In your report you highlight that (1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to the portable oxygen cylinder. (2) That parents and carers should be initially supervised in performing this task until they are deemed to be competent to do so. (3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes. You will recall that, folowing Connor's sad death, the Trust undertook a serious incident investigation with a view to identifying how the safety and quality of our systems and processes could be improved and to ensure the learning was shared. Page 1 of 3 The contents of the report were considered in evidence at the inquest. 1! was reassured to note that the Trust’s investigation report included a number of recommendations which echoed The recommendations contained in your subsequent Regulation 28 report. The Trust’s independent investigator recommended that: e Records of training and competence for basic life support and oxygen therapy for parents and staff should be completed and signed by parents and staff; e A formal risk assessment for patients who have not yet been home with oxygen should be completed by the consultant in charge of the patient’s care. The risk assessment should be used with a checklist to: > Confirm that the appropriate training of parents has occurred; > Confirm that a record of this is documented; > Confirm that the parents are aware of their responsibility for the patient's safety while off the ward (in writing and signed by the parents); > State the length of time that the patient can be absent from the ward (making it clear what time the patient must be returned from the ward) ¢ Prompts to revisit this initial risk assessment should exist and be triggered when there is a change in condition, diagnosis or when an incident occurs either on or off the ward. e Staff should document where parents intend to take the patient before they leave for any trip, and ensure the planned timeframe is within that permitted by the Consultant. « Acheck to ensure that the oxygen cylinder is running correctly should be made before the family leave the ward with the patient. Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report. In summary, the clinical team has devised and implemented three documents which are completed by staff and parents. These are: (a) A risk assessment for parent supervised trips off the ward for children requiring supplemental oxygen; this assessment tool is designed to act as a prompt to ensure all appropriate checks, training, education and documentation is completed for a child who is dependent on supplemental oxygen to be safely taken off the ward by their parents. The first part of this form is completed prior to the first trip away from the ward by each parent intending to supervise the trip and the consultant responsible for the child on the day of the trip. A copy of the form is given to the parent/s and a copy is filed in the child’s notes. The second part of the form is completed prior to each subsequent trip away from the ward. (b) A checklist for patients leaving a ward area who require oxygen therapy; this contains a number of clinical safety prompts including confirmation that the SaO2 has stayed above an agreed level for 48 hours without an increase of oxygen - and if the oxygen requirement has increased in that period the child should not be allowed off the ward; a check to ensure that the cylinder valve is turned to “open” and free flowing oxygen can be felt when the cylinder is turned on; that parents can demonstrate how to turn cylinder on and off; parents can demonstrate how to set cylinder flow rate; a record is made of how long the cylinder will last and confirmation that the parents are aware of this; confirmation that the saturation monitor is fully charged. Page 2 of 3 (c) A risk assessment for delivery of oxygen therapy that staff complete with parents. This includes issues such as the risk of fire or burns from smoking; restriction of oxygen supply if tubing is kinked or trapped; risk of alcohol gels and oil based emollients; and risks of unauthorised adjustment of flow rate on oxygen equipment. As part of this process parents are educated and instructed on the reason for the oxygen; the prescribed flow rate and hours of use; how to operate the equipment safely. ! have attached copies of the documents for your information. Thank you for bringing these matters to my attention. | do hope that this response has assured you that the Trust has given careful consideration to the matters of concern you have raised and had already taken action to address these. If | can be of any further assistance please do not hesitate to contact me. Kind regards Yours sincerely Page 3 of 3
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