Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0091, written 11 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 | 11 Mar 2015 |
|---|---|
| Reference | 2015-0091 |
| Deceased | Neil Westerman |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Stockport NHS Foundation Trust 1 | CORONER ! am John Pollard, senior coroner, for the coroner area of South Manchester 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 the 10" July 2014 | commenced an investigation into the death of Neil Thomas Westerman dob 20" June 1942. The investigation concluded on the 5"" January 2015 and the conclusion was one of misadventure. The medical cause of death was 1a Multi system organ failure 1b Septicaemia 1c Biliary leak following laparoscopic abdominal surgery. 4 | CIRCUMSTANCES OF THE DEATH On the 2"? July 2014 he attended Stepping Hill Hospital for an elective cholecystectomy. The operation led to a leakage of bile causing septicaemia. 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 hing Ma he OF CONCERN are as follows. — During the course of the inquest | heard evidence that the pre-operative assessment was performed by a junior doctor and not by the consultant who was to perform the procedure. This meant that the consultant was unaware of certain vital information. 2. The operation notes did not contain details of the equipment and materials used during the procedure and it was agreed that this should be the case and that all such items should be fully recorded and accounted for at the conclusion of the procedure. 3. I heard evidence, as | have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night. It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren’t enough doctors available. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 6" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely ST (widow of the deceased). | have also sent it to the Care Quality Commission who may find it useful or of interest. | 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, abéuf the release or the publication of your response by the Chief Coroner. 11.3.15 John Pollard, HM Senior 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.
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27" April 2015
Dear Mr Pollard,
Re: Neil Thomas Westerman (Deceased)
Thank you for your letter of 11" March 2015, concerning the inquest of the above named. As always |
am grateful to you for highlighting your concerns on the Regulation 28 ‘Report to prevent future
deaths’ and for providing me with an opportunity to respond.
! am able to address your areas of concern as follows:
A_ concern regarding the pre-operative assessment being carried out by a junior doctor and
not the consultant who was to perform the operation, meaning the consultant was unaware of
vital information.
This is not standard practice in the organisation and was unique to the particular operating surgeon
concerned. Steps have been taken with the individual to ensure that there is not a repeat of this
situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and
with the junior doctor who carried out the pre-operative assessment.
The operating notes did not contain details of the equipment and materials used during the
procedure.
In this case this was an error; it is standard practice to document and record all relevant information
for the related surgery, including the recording of equipment and the numbers of items used. In this
case there was clearly an omission to record such details and the requirement for vigilance in this
respect has been reiterated across the Surgery and Critical Care Business Group.
Despite numbers being in compliance with set guidelines, there were too few junior doctors
on duty to cover the needs of the patients.
We are currently undertaking a review of the general surgical junior doctor rotas; this will include
increased presence on the surgical assessment unit and a more even spread of doctors throughout
the working week. Consideration is also being given to broadening the advanced nurse practitioner
roles; these nurses have the competence and skills to carry out many of the basic junior doctor roles.
The plan is to have these changes in place by the end of August 2015.
| hope that this response answers your concerns and provides you with the assurance that the Trust
is committed to improving the quality of care we give to all our patients.
Please do not hesitate to contact me if you have any further questions regarding this matter.
Yours sincerel
Ann Barnes
Chief Executive
Your Health. Our Priority.
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