Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0155, written 22 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2015 |
|---|---|
| Reference | 2015-0155 |
| Deceased | Noel Jones |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| 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. Chief Executive Worcestershire Acute Hospitals NHS Trust 2. ae 1 | CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 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 17" November 2014 | commenced an investigation into the death of Noel Owen JONES then aged 77 years. The investigation concluded at the end of the inquest on 16 April 2015. The conclusion of the inquest was he died as the result of known complication of necessary surgery the medical cause of death being 1(a) Shock, 1(b) haemorrhage from left iliac artery and perforated descending colon following cystectomy, 2, atherosclerosis, inhalation of gastric contents, ischaemic heart disease, cancer of the upper rectum irradiation for testicular cancer . 4 | CIRCUMSTANCES OF THE DEATH On 2™ October 2014 Mr Jones underwent surgery at the Alexandra hospital. He was later discharged before being admitted on two occasions to the Hereford County Hospital. It is clear that upon his admission to Hereford on 15'" November 2014 he was severely unwell and had sustained an internal haemorrhage. The clinicians at Hereford struggled to have Mr Jones admitted to a variety of hospitals including Worcestershire Royal Hospital. Ultimately when Mr Jones appeared to be in extremis Worcestershire Royal Hospital agreed to accept him and he was rushed there by ambulance but died shortly after his arrival. It appears that there was a four hour delay between the first telephone call to Worcestershire Royal asking for him to be admitted and his ultimate acceptance. 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) Evidence was given that had Mr Jones been accepted by Worcestershire Royal Hospital earlier he would "on the balance of probability" have survived this episode (2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology (3) 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 by reviewing the out of hours or on-call arrangements for vascular surgery or interventional radiology in the case of critically ill patients who needs to be transferred in from elsewhere. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17" June 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 ext of kin) | 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. G U Williams 22nd day of April 2015 H M 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.
Worcestershire NHS) Acute Hospitals NHS Trust Your ref: GUW/TW/W2382.14 Worcestershire Royal Hospital Our ref: CT/jc/INQ/205 (5408) Charles Hastings Way Worcester 17 June 2015 Worcestershire WRS5 1DD PRIVATE & CONFIDENTIAL Mr G U Williams H M Senior Coroner for the County of Worcestershire Worcestershire Coroners Court The Civic Martins Way Stourport-on-Severn Worcestershire DY13 8UJ Dear Mr Williams Re: Noel Owen Jones deceased Regulation 28: Report to Prevent Future Deaths | am writing with reference to your letter dated 22 April 2015 in which you raised two concerns regarding Trust procedures following evidence which you heard at the inquest into the death of Mr Jones. As a result of your letter | confirm that | have reviewed the Trust’s processes in respect of the following action: e Review: the out of hours or on-call arrangements for vascular surgery or interventional radiology in the case of critically ill patients who need to be transferred in from elsewhere. Attached is my response that sets out in detail the Trust’s procedures and the actions which have been taken in response to your concerns. | hope that this information provides assurance to you. However, if you require any additional information please do not hesitate to contact me. Yours sincerely Acting Chief Executive Chairman: Harry Turner Chief Executive: Penny Venables
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