Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0195, written 18 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 | 18 May 2015 |
|---|---|
| Reference | 2015-0195 |
| Deceased | Diana Hughes |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Community health care and emergency services 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.
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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.
Gloucestershire Hospitals INHS| NHS Foundation Trust 1 College Lawn Cheltenham Gloucestershire GL53 7AG e-mail: 13!" July 2015 Ms Katy Skerrett HM Senior Coroner for Gloucestershire HM Coroner’s Office Medico Legal Centre Saw Mills End Barnwood Gloucester GL4 3DJ Dear Ms Skerrett Diana Ruth Hughes | am writing in response to the Regulation 28 report received from you on 22"4 May 2015 in connection with the inquest into the death of Mrs Hughes. | have read the report_carefully and have discussed this case with the Trust’s legal | can confirm that as a result of the Trust’s own internal investigation undertaken before the inquest, the following actions were identified, and work on these actions in underway: 1. Consideration is being given to amending the WHO/Surgical checklist document to include an additional instruction to direct staff at the end of the procedure to check whether ‘special instructions’ for post-operative care have been physically written on the operation note. 2. Consideration is being given to a review of the Trust documentation policy to establish that the record of the surgical/operative procedure should be completed on a new operation note document specifically designed to record that clinical information. In Mrs Hughes’ case, the operation notes were written onto a medical continuation sheet, in red pen. This is currently acceptable Trust policy. 3. It is also intended that any new operation note document incorporates a heading to specifically identify ‘Special Instructions’ for post-operative care This work is being led by Po Consultant General Surgeon and Speciality Director for Surgery, who gave evidence at your enquiry. The progress of these actions will be monitored through the monthly meetings of the Safety Experience and Risk Group (SERG) chaired by iE Director of Safety. Chief Executive: Dr Frank Harsent PhD, MBA www.gloshospitals.nhs.uk Chair: Professor Clair Chilvers DSc ( J BETTER FOR YOU Gloucestershire Hospitals INHS NHS Foundation Trust ! hope this is the information you require. Please do not hesitate to contact me if | can be of further assistance. Yours sincerely ?* Dr Frank Harsent Chief Executive BETTER FOR
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