Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0151, written 19 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Feb 2015 |
|---|---|
| Reference | 2015-0151 |
| Deceased | John Dack |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: Prevention of Future Deaths report
John DACK (died 24.09.14)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
Barts Health
Royal London Hospital
Whitechapel Road
London E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 30 September 2014, I commenced an investigation into the death of
John Dack, aged 58 years. The investigation concluded at the end of the
inquest on 17 February 2015.
I made a determination that death was the result of an accident, when Mr
Dack fell at home on the morning of 8 July 2014, already compromised by
a significant heart condition.
I recorded a medical cause of death of:
1a bronchopneumonia
1b septicaemia
1c fractured left ankle with osteomyelitis (operated)
2 hypertrophic obstructive cardiomyopathy (HOCM)
1
4
CIRCUMSTANCES OF THE DEATH
Mr Dack was admitted to the Royal London Hospital on 8 July 2014, and
diagnosed first with a fracture of his right ankle, and then the following
day a fracture of his left ankle.
Surgeons were worried about his ability to withstand surgery because of
the HOCM and so, on 17 July, he underwent a percutaneous procedure
on each ankle. This was successful on the right, but not on the left, and
so revision surgery was undertaken on the left on 23 July.
Following a multi disciplinary team (MDT) meeting, Mr Dack was
discharged home on 30 July. He was unable to weight bear. He was
never seen for his planned follow up at the Royal London Hospital. I do
not know whether the outcome would have been different if he had been
discharged to a rehabilitation unit rather than home and/or had then been
followed up as intended, but it might.
The likelihood is that at some stage towards the end of August, he
inadvertently put his left foot to the floor and shifted the ankle out of joint.
This led to an infection.
Mr Dack was admitted to the emergency unit of University College
Hospital on 31 August with osteomyelitis and failure of the fixation. The
metalwork was removed and an external fixator applied, but Mr Dack died
on 24 September.
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 MATTER OF CONCERN is as follows.
Mr Dack was not called for follow up because his medical notes recorded
the wrong address for him, despite the fact that one of his daughters had
notified staff of this on two separate occasions. What seems at first blush
to be a relatively unimportant administrative matter can therefore have
serious consequences. I heard from the surgeon treating Mr Dack that
this has happened before with other patients. It seems that this part of
the system of administration would benefit from review.
(No witness was able to offer any suggestions for changes to the hospital
system that might prevent inappropriate early discharge home following
MDT meeting on another occasion.)
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 20 April 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
daughter of John Dack
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 form. He may send a copy of this report to any person who
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
19.02.15
3
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.
Barts Health INHS| NHS Trust Barts Health NHS Trust Trust Executive Offices Ground floor, Pathology Block The Royal London Hospital London, E1 2ES Telephone: www.bartshealth.nhs.uk Ms M E Hassell Senior Coroner for Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 17 April 2015 By special delivery Dear Ma’am, Inquest touching the death of Mr John Dack | write in response to your Regulation 28: Report to Prevent Future Deaths, dated 19 February 2015. Your concern was that Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff. Our investigation has concluded that the ward clerk was told to change Mr Dack’s address by the patient's nurse. A mistake was made however as she recorded him as being of ‘no fixed abode.’ We have asked the ward matron to speak to her staff to remind them of the importance of accurately changing patient details and the consequences of not doing so. This mistake did not however mean that Mr Dack was lost to follow up. On 01 August 2014, an appointment was made for 27 August 2014. Although the address on the appointment system was listed as ‘no fixed abode’, it is likely it was sent to his previous address. Mr Dack phoned the appointment team on 18 August 2014 to change this appointment as it clashed with another appointment. He was given a new appointment for 03 September 2014. On 30 August 2014 he became acutely unwell and was admitted to University College Hospital on that day. There was therefore no need for him to attend his appointment at The Royal London as his condition was already being treated. In conclusion, although a clerical error was made by a member of staff, it is clear Mr Dack did know about his follow up appointment. The importance of accurately changing patient details is being emphasized to the relevant staff. Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, EY The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital. "o & SAB Barts Health INHS| NHS Trust Thank you for bringing your concerns to my attention. | trust that you are assured | have taken them seriously and investigated them appropriately. Yours faithfully Medical Director Barts Health NHS Trust st Bay, S Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, Fe is The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital. Lg . 2 Ware
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