Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0249, written 30 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2015 |
|---|---|
| Reference | 2015-0249 |
| Deceased | Anthony Dwyer |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| 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.
oy North London Coroners Court, Her Majesty's Coroner for the Mo Woe Stes Northern District of Greater London ——Bammet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health Richmond House 79 Whitehall London SWI1A 2NS 1 CORONER lam Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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. a rn 3. | INVESTIGATION and INQUEST On the 10 day of February 2013 | opened an investigation touching the death of Anthony Dwyer , 50 years old. The inquest concluded on the 29" June 2015 The conclusion of the inquest was "Narrative", the medical case of death was 1a Hypoxic cardiac arrest following extubation of endotracheal tube 4 | CIRCUMSTANCES OF THE DEATH On the 9" February 2014 between 10am and 10.30 Anthony Dwyer collapsed in hospital having taken his tracheostomy out from his neck. Anthony Dwyer was a complex,(multiple medical needs), vulnerable, (lacking capacity) long-term tracheostomy patient in a side room,(due to a risk of spread of infection), ina Regional Rehabilitation Unit in hospital. Mr Dwyer was not nursed on a one to one basis and had he been in a bay with other patients, or been looked after continuously in the side room, it is likely that when he took out his tracheostomy tube he would have been seen, and the tracheostomy tube replaced, before Mr Dwyer suffered a hypoxic cardiac arrest. 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. — Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) The adequacy of guidance provided to trust in the general management long term tracheostomy patients with complex medical needs. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 Tuesday 25"" August 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;- Representatives of the family and the Hospital Trust | 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, bout the release or the publication of your response by the Chief Coroner. 30 July 2015
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.
From Ben Gummer MP"
Parliamentary Under Secretary of State for Care Quality
Department
Richmond House
of Health 79 Wheel
POCS5 946053 SW1A 2NS
Tel: 020 7210 4850
Mr A. Walker
Senior Coroner
North London Coroner’s Court
29 Wood Street
Barnet
EN5 4BE
Les Uh Lobe ——
Thank you for your letter of 30" July 2015 following the inquest into the death of
Anthony Dwyer.
I was very sorry to hear of Mr Dwyer’s death and wish to extend my sincere
condolences to his family.
I understand Mr Dwyer was a long term tracheostomy patient who had complex
multiple medical needs. He removed his tracheostomy tube which subsequently led to
collapse and cardiac arrest.
You are concerned that there is inadequate guidance for Trusts about the general
management of long term tracheostomy patients with complex medical needs.
Guidance in this area is the responsibility of the patient safety team at NHS England.
The advice I have received is that adequate guidance is already available for staff
caring for patients with a tracheostomy.
Firstly, the UK National Tracheostomy Safety Project (NTSP) has developed a range
of resources to improve care for patients with a tracheostomy which can be found at:.
http://www.tracheostomy.org.uk/
The NTSP Manual (2013) was developed in collaboration with key stakeholders,
including the Intensive Care Society, the Royal College of Anaesthetists, the College
of Emergency Medicine, the Resuscitation Council UK and the Royal College of
Nursing. It covers all aspects of tracheostomy management including guidance on
observing patients with a tracheostomy. It states:
... as a general rule the patient should be nursed in an open observation area, rather
than a side room (unless continuous 1:1 staffing is provided). Discussion with
infection control teams should take place as close observation for airway compromise
is likely to take priority over use of a side room for infection control purposes.
The Manual is supplemented with e-learning modules and videos.
Further resources include the report, Tracheostomy Care: On the Right Trach?
published by The National Confidential Enquiry into Patient Outcome and Death
(NCEPOD), which is available at:
http://www.ncepod.org.uk/2014tc.htm
This report was published with a self-assessment checklist for trusts, allowing the
monitoring of progress in adopting NCEPOD's recommendations.
The Intensive Care Society (ICS) has issued updated standards and guidelines on
tracheostomy care:
http://www.ics.ac.uk/ics-homepage/guidelines-and-standards/
Finally, the Global Tracheostomy Collaborative, an initiative launched in the UK,
aims to improve tracheostomy care through international collaboration including
benchmarking the quality of care. Further details can be found at:
http://www.globaltrach.org
NHS England will continue to work with stakeholders to identify and act on
tracheostomy issues, They will also work with Dr Brendan McGrath, the National
Tracheostomy I-ead{Clinician, who was recently nominated for the role of National
Clinical Advisor to’NHS England.
se
BEN GUMMER
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