Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0159, written 23 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 | 23 Apr 2015 |
|---|---|
| Reference | 2015-0159 |
| Deceased | Patricia Chapman |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | County Durham and Darlington 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 THIS REPORT IS BEING SENT TO: 1. County Durham and Darlington NHS Trust, Darlington Memorial Hospital, Hollyhurst Road, Darlington DL3 6HX !am Andrew Tweddle Senior Coroner, for the coroner area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 30" July 2013 | commenced an investigation into the death of PATRICIA LILLIAN CHAPMAN, Aged 77 years. The investigation concluded at the end of the inquest on 21st April 2015 The conclusion of the inquest was “The avoidable consequence of an avoidable hypoglycaemic episode”. with a cause of death of Hypoglycaemia. CIRCUMSTANCES OF THE DEATH The deceased was a patient at Sedgefield Community Hospital. In the aftemoon of the 8" of July 2013 she had a severe Hypoglycaemic attack but following an injection, apparently recovered. In the early morning of the next day she died from another Hypoglycaemic attack. The inquest has revealed a number of shortcomings with regard to the deceased's care. Many changes in practice policy and procedure have been implemented since her death. 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) The revised training and flow chart does not include any reference to staff ina community hospital being able to obtain emergency advice from an expert in the emergency department of one of the Trust’s acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after having been summoned. It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient's safety and this is not included in the revised Trust policies. This is something that should be given consideration to. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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, 8 namely by 18" 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 Person A arc the COC. | 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. 23 Aptil 201 HM Senior Coroner County Durham and Darlington SCHEDULE 5 paragraph 7 ACTION TO PREVENT OTHER DEATHS 1)Where— (a)a senior coroner has been conducting an investigation under this Part into a person's death, (b)anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c)in the coroner's opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. (2)A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3)A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner. Regulations 28 and 29 Report on action to prevent other deaths 28.—(1) This regulation applies where a coroner is under a duty under paragraph 7(1) of Schedule 5 to make a report to prevent other deaths. (2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner. (3) A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation. (4) The coroner— (a) must send a copy of the report to the Chief Coroner and every interested person who in the coroner’s opinion should receive it; (b) must send a copy of the report to the appropriate Local Safeguarding Children Board (which has the same meaning as in regulation 24(3)) where the coroner believes the deceased was under the age of 18; and (c) may send a copy of the report to any other person who the coroner believes may find it useful or of interest. (5) On receipt of a report the Chief Coroner may— (a) publish a copy of the report, or a summary of it, in such manner as the Chief Coroner thinks fit; and (b) send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest. Response to a report on action to prevent other deaths 29.—(1) This regulation applies where a person is under a duty to give a response to a report to prevent other deaths made in accordance with paragraph 7(1) of Schedule 5. (2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner. (3) The response to a report must contain— (a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or (b) an explanation as to why no action is proposed. (4) The response must be provided to the coroner who made the report within 56 days of the date on which the report is sent. (5) The coroner who made the report may extend the period referred to in paragraph (4) (even if an application for extension is made after the time for compliance has expired). (6) On receipt of a response to a report the coroner— (a) must send a copy of the response to the report to the Chief Coroner; (b) must send a copy to any interested persons who in the coroner's opinion should receive it; and (c) may send a copy of the response to any other person who the coroner believes may find it useful or of interest. (7) On receipt of a copy under paragraph (6)(a) the Chief Coroner may— (a) publish a copy of the response, or a summary of it, in such manner as the Chief Coroner thinks fit; and (b) send a copy of the response to any person who the Chief Coroner believes may find it useful or of interest (other than a person who has been sent a copy of the response under paragraph (6)(b) or (c)). (8) A person giving a response to a report may make written representations to the coroner about— (a) the release of the response; or (b) the publication of the response. (9) Representations under paragraph (8) must be made to the coroner no later than the time when the response to the report to prevent other deaths is provided to the coroner under paragraph (4). (10) The coroner must pass any representations made under paragraph (8) to the Chief Coroner who may then consider those representations and decide whether there should be any restrictions on the release or publication of the response.
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.
County Durham and Darlington NHS Foundation Trust Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX Our Ref: SJ/bc/Coroner 18" June 2015 Mr Andrew Tweddle HM Coroner for the North & South Districts of Durham & Darlington HM Coroner's Office PO Box 282 Bishop Auckland Co Durham DL14 4FY Dear Sir, Patricia Lillian Chapman | am responding to the content of your letter and specifically those issues raised within your report under Regulation 28 and 29 of the Coroners Investigations Regulations 2013. The Matters of Concern as you stated: ‘The revised training and flowchart does not include any reference to staff in a community hospital being able to obtain emergency advice from an expert in the emergency department of one of the Trust’s acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after being summoned. It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient’s safety and this is not included in the revised Trust policies. This is something that should be given consideration to.’ This letter is to confirm that all qualified staff at Sedgefield Community Hospital have received training in the deteriorating patient and management of a patient with hypoglycaemia. If a patient with diabetes is admitted to any community hospital the “Management of Hypoglycaemia” flowchart is inserted into the front of the nursing care record to act as a teference guide. www.cddft.nhs.uk Chief Executive, Darlington Memorial Hospital, Hollyhurst Road, Darlington, County Durham DL3 6HX Tel: 01325 743565 We have also introduced an operational procedure for community hospital staff who may require urgent advice whilst waiting for an ambulance to arrive, as follows: OPERATIONAL PROCEDURE COMMUNITY HOSPITALS On occasion it may be necessary to seek urgent advice on the management of a patient within a community hospital whilst waiting for an emergency ambulance to arrive. Process to follow 1) Dial 999 — always first action. 2) Ensure a registered nurse stays with the patient. 3) Implement immediate actions as per trust policy. 4) Summon on site qualified medical practitioner. If urgent advice is required whilst waiting for an ambulance and there is no qualified medical practitioner on site: Contact acute hospital switchboard — Telephone No. 01325 380100 Between 8:00am — 8:00pm each day ask for Medical Consultant Physician of the day Between 8:00pm — 8:00am each day ask for Medical Registrar on call Be concise regarding the immediate advice you require and what the issues are regarding patient management whilst waiting for an ambulance to arrive. Yours sincerely, Some SD, Sue Jacques Chief Executive IM noA u} < www.cddft.nhs.uk Chief Executive, Darlington Memorial Hospital, Hollyhurst Road, Darlington, County Durham DL3 6HX Tel: 01325 743565 Aem au} ye
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