Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0097, written 13 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 | 13 Mar 2015 |
|---|---|
| Reference | 2015-0097 |
| Deceased | James McManus |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Acute Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: 1. The Chief Executive, Pennine Acute Hospitals NHS Trust 1 CORONER I am Ms L Hashmi, Area Coroner for the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 19th February 2015 I commenced an investigation into the death of Mr James Mc Manus. 4 CIRCUMSTANCES OF DEATH Against the backdrop of pre‐existing comorbidities, the deceased was admitted to the Royal Oldham Hospital on 8th October 2013 with a diagnosis of acute lower limb ischaemia that necessitated urgent medical intervention. Thrombolysis therapy was commenced on 9th October but stopped on 10th October due to the development of bleeding. Therapy was recommenced on 18th October. In the early hours of the 20th October the deceased began to show signs of hypovolaemic shock. Fluid resuscitation was initiated. Thrombolysis therapy was not discontinued until 14:00 the same day. Trust protocols were not followed and the resuscitation process was sub optimal. No consultation took place with a Consultant Haematologist. The deceased continued to deteriorate. He died on 3rd November 2013 as a result of the recognised but rare complications of necessary medical intervention. 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. I am concerned about the lack of knowledge, application and implementation of key protocols by Trust staff – in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of massive blood loss. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 the 11th 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- - The deceased’s family - The Chief Coroner for England & Wales 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 from. 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: 13th March 2015 Signed:
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.
i!1LZ1 The Pennine Acute Hospitals I •1 NI-iS Trust Pennine Ifcalling please askfor: North Manchester General Hospital Delaunays Road Direct Line: Crumpsall Secretary: Manchester M8 5RB Ourreference: AS/KH Date: 12 May2015 e-mail: Strictly Private and Confidential To be opened by Addressee only Mrs L Hashmi H M Coroner H M Coroner’s Court The Phoenix Centre Church Street Heywood OL1O 1LR Dear Mrs. Hashmi, Re: Inquest touching the death of Mr James McManus 19 February 2015 Please find the Trust response to the recent Regulation 28: report to prevent future deaths, served to the Trust on 13 March 2015. You commented in your conclusion and also expressed in your concerns about the lack of knowledge, application and implementation of key protocols by Trust staff, in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of blood loss. On your advice, the Trust has taken action to prevent future deaths as documented below. This work has been led by Vascular Surgeon and Clinical Lead for Anaesthetics. New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology 27 Consultants. The session dates were held on the following dates, 14th and October 2014 and on l0hl and 24th November 2014. • Development of a training presentation incorporating the policies and guidelines regarding Thrombolysis and management of associated bleeding risks. This presentation will take place on 22 May 2015, during the Clinical Governance Audit session, attendance is mandatory for all levels of medical staff. , Vascular Surgeon and Clinical Lead for Anaesthetics will lead on this presentation. Prior to the audit day the Directorate Manager for Vascular Surgery will ensure that all levels of vascular medical staff receive copies of the policies to be discussed. • Development of a training presentation incorporating Clinical Record Keeping. Presentations will be delivered on the Clinical Governance Audit sessions. The Directorate Manager for Vascular Surgery is arranging this as a matter of priority, with an expected completion date of September 2015. Staff will be advised that all discussions, multidisciplinary meetings that are held and decisions made regarding patient management plans are to be clearly documented as a permanent record in the patient’s case notes. • Review of Adult Critical Care Operational Policy this will incorporate a mechanism that - enables a senior member of a referring Consultants Team, to liaise with the consultant Intensivist when the consultant surgeon is unavailable (i.e. if they are scrubbed in theatre.) This will include Vascular and Anaesthetic consultants and representatives from the Divisions of Surgery, Medicine and Women and Children’s. The Directorate Manager is arranging this meeting with and the intention is that this will be completed by July 2015. • Development of training regarding the improvement of communication pathways between clinicians and specialities. Presentations will be delivered on the Clinical Governance Audit Sessions and Directorate meetings during 2015. The final target date for completing these presentations will be December 2015 with the Directorate Manager arranging these as a matter of high priority. In order to confirm that all actions are implemented the Senior Directorate Manager will have overall responsibility for ensuring the completion of the actions within the assigned dates. This will include spot checks on the quality of health records with support from the clinical audit team. I would wish to offer sincere condolences on behalf of the Trust and myselfto Mr McManus’ family. I am attaching the key policies in appendix 1. If there is any further information that you require please do not hesitate to contact me. Yours sincerely .— — Acting Medical Director
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