Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0122, written 30 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 | 30 Mar 2015 |
|---|---|
| Reference | 2015-0122 |
| Deceased | Kelly Willis |
| Coroner | Rachel Redman |
| Coroner area | Kent (Central & South East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Kent Hospitals University 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: Mr S Bain Chief Executive East Kent Hospitals University NHS Trust Kent and Canterbury Hospital Ethelbert Road Canterbury CT2 3NG 1 | CORONER | am Rachel Redman Senior Coroner, for the Coroner area of Central and South East Kent. 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 15 September 2014 | commenced an investigation into the death of Kelly Patrick WILLIS. The investigation concluded on 25 March 2015. | reached a narrative conclusion, a copy of which is attached. 4 CIRCUMSTANCES OF THE DEATH Kelly Patrick Willis underwent ablation for atrial fibrillation at St Thomas’ Hospital on 8! October 2012. He was discharged the following day. Dr [J the Consultant Cardiologist and Electrophysiologist who operated on him emailed Dri Consultant Cardiologist at William Harvey Hospital on 10‘ October and advised her that if Mr Willis began to feel unwell after a period of one week that he should be contacted to exclude ‘rare complications (e.g. atrial oesophageal fistula)’. Mr Willis developed symptoms of general unwellness which required him to be admitted to William Harvey Hospital on 14" October, 22"4 October and 25'" October. On the first and third admission it was noted on admission that he had undergone a procedure at St Thomas’ Hospital who should be contacted. In spite of this documentation, it was not until Dr] reviewed the patient on 29" October that contact was made with St Thomas’ Hospital. Dr [J was unable to account for when she read Dr [iiemail and the Ward Clerk, at the end of the second admission, was requested to fax a copy of the Electronic Discharge Notification to St Thomas’ Hospital but failed to do so for a further seven days until 30'" October. The cause of death was: 1a) Cerebral infarction 1b) Multiple septic emboli 1c) Atrio-oesophageal fistula complicating atrial ablation (08.10.12) for paroxysmal atrial fibrillation. 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 these circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. e Those caring for Mr Willis at William Harvey Hospital recognised the need to contact St Thomas’ Hospital about the procedure that he had undergone there but failed to liaise with the tertiary centre before 29'" October, even though this was well documented in the medical records on the first and third admissions that it should be. | am of the opinion that contact with the tertiary centre which had operated on Mr Willis should have been made when he first presented at William Harvey Hospital on 14" October, and thereafter on 224 October and on 25" October as Dr| had requested. ¢ Dr did not act on the email sent to her by Dr}. Had she liaised with him it is likely, given his flu-like illness and increasing white cell count, that he would have been investigated with CT imaging either at St Thomas’ Hospital or William Harvey Hospital at an earlier stage than 29" October, thus allowing the opportunity to — to exclude rare complications, as he requested in his email to Dr| ACTION SHOULD BE TAKEN e | believe that if it is documented in the medical records that action should be taken, then that request should be followed. e | consider that early contact should be made with tertiary centres which have carried out procedures or treatment in circumstances where their patient is subsequently admitted to William Harvey Hospital without a confirmed diagnosis. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Field Fisher Waterhouse LLP Clyde & Co DAC Beachcroft | 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. Signed: 30 March 2015 Rachel Redman
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.
East Kent Hospitals University NHS) NHS Foundation Trust Rachel Redman Trust Offices HM Coroner Central and South East Kent Kent & air abies Elphicks Farmhouse Canterbury Hunton Kent CT1 3NG Kent ME15 OSB Tel: 01227 866308 Our Ref: 07 May 2015 From the Interim Chief Executive, fF Dear Ms Redman Re: Kelly Patrick WILLIS (deceased) Following the conclusion of the Inquest hearing touching upon the death of Kelly Willis on 25th March 2015 and pursuant to Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, | set out below the actions and considerations taken by East Kent Hospitals University NHS Foundation Trust in respect of your findings. 1. Follow up of documented actions There are regular, daily handover sessions between the separate clinical and nursing staff when there is a change over in shift pattern of staff covering the hospitals' sites. During these handover sessions it is expected that staff inform those coming on duty of any outstanding actions to be taken in respect of the individual patients on the wards. This includes informing staff of the importance of following up any actions which remain outstanding at the time of handover. In addition, clinical staff are expected to review the more recent entries within a patient's healthcare record at the time when they attend to a patient, in order to ensure that they are aware of the pre-existing documentation within the patient's healthcare records and to assist in informing future clinical decisions which may need to be taken. At the time when reviewing the healthcare records, and where it is observed that an action is outstanding, consideration is given as to the appropriateness of furthering the action in view of the patient's current clinical condition. Where there is concern as to the appropriateness of following up a documented action, it is my expectation that the individual's concerns are escalated to a senior member of staff for further consideration/discussion. Any revisions to action plans should be clearly documented within the healthcare records to not only record the care decided upon and given, but also to inform future decision making and on-going treatment plans. 2. Prompt Contact with Tertiary Referral Centres The Trust recognises that earlier contact should have been made with a St Thomas' Hospital following Mr Willis' admission to the William Harvey Hospital, particularly because his diagnosis was unconfirmed. It is not uncommon for patients to undergo treatment at tertiary centres and for their care to subsequently be referred back to that of the Trust either as a direct referral or following readmission to hospital from the community setting, as in Mr Willis' case. It is not ihe Putting vatients first Rachel Redman 07 May 2015 Page 2 appropriate or necessary for contact with tertiary centres to be made for all patients who subsequently return to our care, but it is appropriate in circumstances where patients suffer rare complications of procedures which they have undergone, such as in the case of Mr Willis. | fully understand that had timely contact been made with i Mr Willis may have been offered further treatment for his condition and whilst the prognosis of long term survival would have been poor, he may have received alternative clinical care and management. In order to bring your concerns to the attention of the clinical and nursing staff within the Trust an article will be included in the regular publication produced by the central Risk Management Team entitled Risk Wise. This publication is disseminated electronically to all members of Trust staff and is produced on a quarterly basis. The article will include reminders to all staff of the importance of ensuring that requested actions which are either documented within the healthcare records or advised of during handover sessions, and which appear to be outstanding at the time of review are reassessed with a view to subsequent completion. The article will also inform the reader of the importance of considering the need to make contact with tertiary treatment centres for further guidance and patient management, particularly where a patient has already received treatment from that centre. A copy of the published bulletin will be sent to you in due course. | would like to take this opportunity to thank you for your letter and to reassure you that we have taken your comments on board and will continue our commitment to deliver a safe and effective service to our patients. Yours sincerely Interim Chief Executive ale =e =e Gre
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