Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0161, written 24 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 | 24 Apr 2015 |
|---|---|
| Reference | 2015-0161 |
| Deceased | Hilda Harris |
| Coroner | Sarah-Jane Richards |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| 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 Coroner 2. Minister for Health, National Assembly for Wales 3. tive, Cwm Taf University Health Board 4 Cee EES 1 CORONER | am Dr. Sarah-Jane Richards, Assistant Coroner, for the coroner area of Powys, Bridgend and Glamorgan Valleys 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 the 16" January, 2015 | commenced an investigation into the death of Mrs. Hilda May Harris. The investigation concluded at the end of the inquest on the 17" April, 2015. The conclusion of the inquest was ‘natural causes exacerbated by prescribed medication’. 4 | CIRCUMSTANCES OF THE DEATH Mrs. Harris (86 years) suffered a previous myocardial infarction and cerebral vascular accident. She also suffered from gout. In or around October 2014 her Consultant Cardiologist, prescribed Warfarin and in consequence, Mrs. Harris’ INR levels were monitored by te Community District Nurse team albeit, dose adjustments were the responsibility of the Royal Glamorgan Hospital. In December 2014, Colchicine and Allopurinal medications were prescribed to treat a flare up of Mrs. Harris’ gout. As either drug could affect the metabolism of Warfarin, an additional INR check was requested by the hospital for the 30.12.14. Although the request was received by the District Nurses’ office, it was not transferred from one sheet of papers to another. In consequence, the INR test was not undertaken. Mrs. Harris’ daughter, Fe had been warned by the pharmacist of the importance of INR monitoring when combining Allopurinal with Warfarin. Thus. when the District Nurse failed to undertake the INR test as arranged by the hospital, contacted the GP surgery to advise of the omission. This message, although noted by the surgery, was not received or not acted upon by the Community District Nurses. On the 04.01.15, Mrs. Harris suffered a cerebral infarction with an intra-cerebral haemorrhage. Pathologist iMRI tributed the extensive bleed to elevated levels of Warfarin. 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 untess action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the Notification system (by the family or carers) also appears unreliable. (6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action in the area of: > Ensuring a dependable system of booking INR testing with the Community District Nurse team is established; and > Ensuring a dependable system for communication between patients and their community District Nurses. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22™ 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, Mr. Mark Drakeford, Minister of Health, National Assembly for Wales; Mrs. Allison Williams, Chief Executive, Cwm Taf University Health Board; a Consultant Cardiologist, Cardiolo — Royal Glamorgan Hospital; and to the family cerresentative, | 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. 24” April 2015 SIGNED: Dr. Sarah-Jane Richards HM Assistant 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.
4 ten GIG Bwrdd lechyd Prifysgol YMRU | Cwm Taf \oZ H University Health Board WALES Dr Sarah-Jane Richards Her Majesty’s Assistant Coroner for Bridgend and the Glamorgan Valleys The Coroner's Court 01443 744800 Rock Grounds Aberdare CF44 7AE 16 June 2015 Dear Dr Richards, Re: Regulation 28 Report Hilda Harris (died 4.1.2015) I refer to your e mail correspondence sent on 27" Apri! 2015, enclosing the Regulation 28 report, which details the areas of concern following your conclusion of the inquest on 17th April 2015 touching on the death of Mrs Hiilda Harris on 4" January 2015. Please be assured that the Health Board has taken this matter extremely seriously, has learnt lessons following investigation and the matters raised at the inquest into the circumstances. Comprehensive and robust action has been taken to minimise the risk of any recurrence. 1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement was developed to capture the Health Boards comprehensive response; this is attached. 2. Actions implemented I can confirm that the actions have been taken forward by the Primary Community & Localities Directorate. The progress made is reflected in the plan as attached. I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigations into the care provided to Mrs Harris, and that effective action has now been taken to prevent future deaths. I would like to convey once again my deepest sympathy and sincere apologies to Mrs Harris’ family for the failings identified. Ld GIG | ewrdd lechyd Prifysgol Lay NHS Cwm Tat QW N ee HS University Health Board If you require any additional information or clarification please do not hesitate to contact me. Yours sincerely Mrs AJ Williams Chief Executive Officer Cwm Taf University Health Board
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