Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0189, written 15 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 May 2015 |
|---|---|
| Reference | 2015-0189 |
| Deceased | George Richardson |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | City Hospitals Sunderland 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.
Derek Winter
Senior Coroner for the City of Sunderland
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Rt Hon Jeremy Hunt
Secretary of State for Health
Department of Health
Richmond House
79 Whitehall
London SW1A 2NS
1 CORONER
1 am Derek Winter, Senior Coroner for the City of Sunderland
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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www legislation.gov.uk/uksi/2013/1629/part/7/made
3 INVESTIGATION and INQUEST
On 12" February 2015 | commenced an investigation into the death of George Richardson, aged
84. The investigation concluded at the end of the Inquest on 12th May 2015.
The conclusion of the Inquest was a “Natural occurring heart condition contributed to by
complications from catheterisation”.
4 CIRCUMSTANCES OF THE DEATH
George Richardson died in Sunderland Royal Hospital on 9th February 2015 at 05:10 hours
having been admitted on 20th January 2015. He went into urinary retention and required
catheterisation on several occasions by different individuals during which time he suffered
urethral trauma,
The cause of death following the Post Mortem Examination was: -
la Ischaemic Heart Disease;
Ib Coronary Artery Atheroma;
{1 Traumatic Urethral Catheterisation and Infective Exacerbation Of Chronic Obstructive
Pulmonary Disease.
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. —
Catheterisation was carried out including attempts/manipulation on several occasions by
different individuals without recourse to a consolidated catheterisation record. Individuals were
not always aware of previous catheter challenges so as to promote the involvement of a
Civic Centre, Burdon Road, Sunderland, SR2 7DN
Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland
www.sunderland, gov.uk/coroner
Urologist.
The Trust are addressing their Catheterisation Policy but as there are 33,000 such procedures
undertaken there each year, the skills required for safe and effective catheterisation may require
national standards to be set.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
by Monday 13" July 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons: -
e Family
e City Hospitals Sunderland NHS Foundation Trust and their Solicitors
e Care Quality Commission
| 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.
Dated this 19
Signature
Senior Coroner tor
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.
a8 | Department | of Health POCS 935695 Derek Winter HM Senior Coroner for the City of Sunderland Civic Centre Burdon Road Sunderland SR2 7DN Thank you for your letter to the Secretary of State about the death of George Richardson. I am responding as the Minister with responsibility for service quality at the Department of Health. I was sorry very to hear of Mr Richardson’s death and would be grateful if you would pass on my condolences to his family. ; an yo: . Your report details and prfacceptable failure in patient care at Sunderland Royal Hospital and asked whether there was a need for national guidance on catheterisation, given the number of these procedures carried out within the NHS each year. NHS England (NHSE) confirms that there are, at present, two sources of national guidance in the UK: 1. National Institute for Health and Care Excellence guidance - focussed on prevention of infection related to urethral catheters, which can be found at: https://www.nice.org.uk/guidance/qs6 1/chapter/quality-statement-4-urinary- catheters#source-guidance-4. 2. The Royal College of Nursing (RCN) guidance - ‘Catheter Care — RCN guidance for Nurses’, which can be found at: https://www.ren.org.uk/__data/assets/pdf_file/0018/157410/003237.pdf The RCN publication aims to encourage further adoption of the National Occupational Standards (which describe best practice by bringing together skills, knowledge and values) across all NHS and independent health care sectors. National Occupational Standards may also be used as benchmarks for qualifications. The guidance includes a suggested structure for gaining competence in catheterisation, including a comprehensive section on the importance of accurate documentation, which is clearly relevant to Mr Richardson’s case. We understand the British Association of Urological Nurses (BAUN) has chosen not to develop a separate national guideline on catheterisation to avoid duplication and potential confusion with both the RCN publication and the European Association of Urology Nurses (EAUN) guidance relating to all aspects of catheter care, published in 2012. The EAUN guidelines, entitled ‘Evidence-based Guidelines for Best Practice in Urological Health Care — Catheterisation, Indwelling catheters in adults - Urethral and Suprapubic’ can be found at www.baun.co.uk/index.php/download_file/view/304/226/ While neither of these publications advise on the number of attempts at re- catheterisation prior to seeking specialist assistance from a urologist or urology nurse specialist, it is generally to be expected that senior/ specialist assistance should be sought when a clinician finds difficulty in any procedure. The British Association of Urological Surgeons (BAUS) has advised that the issue of when and how to seek more senior help following repeated failed attempts at catheterisation is best managed by local, rather than national, guidance. Appropriate national guidance already exists. Ensuring staff know of it, and how and when to seek help where catheterisation proves problematic, is for hospital Trusts to action locally. For the future, should BAUS determine a need for further national advice, NHS England would support its dissemination. T have also passed your repprt to Anne Bishop, Chief Executive of BAUS, and to Fiona Sexton, the President of BAUN, who have been asked to write to you on this issue, Thank you for brirging’this matter to our attention BEN GUMMER
See every Prevention of Future Deaths report matching City Hospitals Sunderland NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.