Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0167, written 29 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 | 29 Apr 2015 |
|---|---|
| Reference | 2015-0167 |
| Deceased | Barry Wilson |
| Coroner | Pritchard Jones |
| Coroner area | North West Wales |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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D. Pritchard Jones’, Senior Coroner for North West Wales ee REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Medical Director, Glan Clwyd Hospital, Rhuddlan Road, Bodelwyddan, Denbighshire. LL18 5UJ i CORONER am D. Pritchard Jones, Senior Coroner for North West Wales 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.qov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 31/12/2014 | commenced an investigation into the death of Barry Wilson, aged 70 years . The investigation concluded at the end of the inquest on 22 April 2015, The conclusion of the inquest was that Death was due to misadventure. Mr. Wilson had been admitted to Glan Clwyd Hospital on the 19th December with abdominal pain and a CT scan confirmed bowel obstruction. He was operated on 20th December and on 24th December he was discharged from hospital. On discharge he was in severe pain on mobilising and collapsed at his home. He was taken to Ysbyty Gwynedd, Bangor on 25th December 2014 where life was pronounced extinct at 16.07 hours. CIRCUMSTANCES OF THE DEATH COD: (1a) Peritonitis (1b) Anastamotic breakdown (1c) Right hemicolectomy 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) It would appear from the evidence that the deceased had undergone a right hemicolectomy and that the anastomosis had been made with staples. The anastomosis was defective and this should have been apparent either on or prior to the deceased’s discharge from hospital. If the defect had been detected at that stage Mr. Wilson might not have died. 37 Castle Square, Caernarfon, Gwynedd, LL55 2NN Tel 01286 672804 | Fax 01286 675217 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Medical Director, Glan Clwyd Hospital have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 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 || ho may find it useful or of interest. lam 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. Dated 29 April 2015 vet et UV ee le , « D. Pritchard Jones Senior Coroner for North West W; 37 Castle Square, Caernarfon, Gwynedd, LL55 2NN Tel 01286 672804 | Fax 01286 675217
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.
Bwrdd lechyd Prifysgol Betsi Cadwaladr University Health Board SQN (> yw fat Y =— Z20 = ALE w Mr. D. Pritchard jones HM Senior Coroner North West Wales. 37 castle square, Caernarfon, Gwynedd, LLS5 2NN Dear Mr. Pritchard Jones Ysbyty Glan Clwyd, Y Rhyl, Sir Ddinbych, LL18 5UJ Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ Ein cyf / Our ref: Eich cyf / Your ref: _ a: Gofynnwch am / Ask for: Ffacs / Fax: E-bost / Email: Dyddiad / Date: Tuesday, June 16, 2015 Re: Regulation 28 Letter 29"" April 2015, with respect to Barry Wilson (Deceased) As most correctly observed by m7 anastomotic breakdown is a recognized risk of the surgery Mr. Wilson underwent prior to his unfortunate death. Further elaboration | feel would be helpful, and seeking this | have sought the advice eC Consultant Colo- Rectal surgeon, which he sets out as follows — Anastomotic leak is a recognised complication of all colonic resections, including right hemicolectomy. The rates of anastomotic leak are reported very widely and variably something in the region of approximately 2% — 17%. The incidence of anastomotic leak is increased in emergency patients and depends on patient factors, as well as technical factors, Even if an anastomosis is made at the time of. surgery without any apparent technical problems, it is still possible that the patient can develop an anastomotic leak. An anastomotic leak can occur any time Jrom immediately after the procedure to sometime afterwards, perhaps up to 2 weeks later. An anastomotic leak can present sub-clinically with no Symptoms or can present with severe symptoms immediately such as peritonitis etc. The presentation of anastomotic leak is variable and difficult to predict. As the time at which an anastomotic leak is variable it may occur after the Patient is discharged Srom hospital. This is particularly so with the new enhanced recovery programs where people are kept in hospital for a lesser amount of time following surgery than previously. It is common jor Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr | Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk patients to be discharged early following surgery (2 -3 days post op being common practice nationally) when they are feeling well and it may be that an anastomotic problem can happen after they have been discharged. All patients are advised about anastomotic leak in the pre-operative procedures and during consenting, (as was the patient in question, and as indicated on the consent form) and given verbal advice about what to do if they are unwell following discharge. They receive written information about the operation and potential complications before the procedures. Through this Regulation 28 you require | take to action to “prevent future deaths”. These | see as a. That we put in place mechanisms which ensure prior to and at the point of discharge we confirm and document key assessments have been made (e.g. pain control),and advice provided as information sheets b. As part of this process follow up arrangements, to include direct contact within 48 hours, by a Colo-Rectal Nurse specialist bringing the service these emergency patients receive in-line with that already in place for those under-going colonic procedures on an elective / scheduled basis. This being the case we will by (unless otherwise specified) the 6th July ensure the following are in place e Pre-Discharge check-list- (example enclosed). Consistent with normal current practice for patients undergoing day case surgery, a checklist will be completed on discharge of all patients from the Colo-Rectal Ward e All other Surgical Wards in Glan Clwyd required to develop and put in place appropriate check-lists by end July. e Patients to be provided with clear information leaflet (by end July 2015) which will outline o Symptoms and signs of concern o Those which may occur, yet not of concern o The direct dial contact numbers for the Ward in the event of concern o The expectation where instructed by ward staff, patients return directly to the colo-rectal ward for assessment, initially by ward Nursing Staff, and thereafter by the surgical registrar communicating his / her findings to the Consultant who performed the surgery & /or On-Call ° Care of these patients to align with that of planned surgery (start by the 6" July) o Patients required to report by telephone to ward daily until contact by Colo- Rectal Nurse Specialist o Colo-Rectal Nurse specialist to contact within 48 hours, or as soon as return to normal work after a week-end. Anastomotic breakdown a known complication, our team believe Mr. Wilson is likely to have been told who and when to contact with any concerns. However, prompted to look more closely we have identified gaps in our processes and documentation which have made such beliefs difficult to confirm. Committing to these actions, though specific to emergency bowel resection, we note the wider lessons. | hope through this letter you are re-assured, and trust you will contact me directly should you require anything further. Yours sincerely Site Medical Director Glan Clwyd Hospital
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