Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0251, written 1 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 | 1 Jul 2015 |
|---|---|
| Reference | 2015-0251 |
| Deceased | Mary Hyden |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mark Hackett : Chief Executive University Hospital North Midlands Stoke on Trent 1 CORONER I am Mr Andrew Haigh Senior Coroner for the Coroner area of Staffordshire South 2 CORONER’S LEGAL POWERS I 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 23rd February 2015 I commenced an investigation into the death of Mary Winifred HYDEN, aged 88 years. The investigation concluded at the end of the inquest on 23rd June 2015. The conclusion of the inquest was "A naturally occurring intracranial tumour that was not successfully treated" With the cause of her death being 1a Pulmonary Thrombo-embolism 1b Suprasellar meningioma. 4 CIRCUMSTANCES OF THE DEATH Mrs Hyden was referred to a neurologist in 2013 and after a CT scan was found to have a tumour by her brain. She saw the neurologist again in 2014 but still no information about the tumour was given to her or her GP. It may be that at no time was curative surgery possible in any event but there could at least have been better palliation of her symptoms. She died at home on 16th February 2015. 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. – Consultant (1) At the inquest I heard helpful evidence from Neurologist. She was frank about failures in communication in 2013 and 2014 and advised me of significant changes since Cannock Hospital was transferred to the Wolverhampton Trust. However working regularly 7 days a week and the day before the inquest worked 14 hours (and again this was not unusual). These do appear to be excessive hours with an increased potential for fatal errors. I should be grateful if you could look at this. also indicated in evidence that she is 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: sister of deceased) I am also under a duty to send the Chief Coroner a copy of your response. ( daughter of deceased) and ( 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. 9 1st July 2015 Andrew A Haigh HM Senior Coroner Staffordshire (South)
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.
University Hospitals of North Midlands NHS) NHS Trust Your Ref: AAH/EAW 359-2015 * Executive Suite Our Ref: INQ/091/15 Trust Headquarters Date: 24 August 2015 Springfield City General Site Newcastle Road Stoke on Trent STRICTLY PRIVATE & CONFIDENTIAL Mr A Haigh $14 606 Coroner's Office Tel: 01782 676612 No 1 Staffordshire Place Stafford i Email S716 21P 2 Dear Mr Haigh Mary Winifred HYDEN Further to my letter dated 10 July 2015, | am pleased to provide a response to your report under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of Mrs Mary Hyden. Background Mrs Hyden was referred to a neurologist in 2013 and after a CT scan was found to have a tumour on her brain. She saw the neurologist again in 2014 but still no information about the tumour was given to her or her GP. It may be that at no time was curative surgery possible in any event but there could have at least been better palliation of her symptoms. She died at home on 16 February 2015. The Conclusion of the inquest was a naturally occurring intracranial tumour that was not successfully treated. Concerns During the course of the inquest H M Coroner, Mr Haigh, felt that evidence revealed matters giving rise for concern. In his opinion, matters for concern are as follows: 1, At the inquest Mr Haigh heard helpful evidence from (EEE Consultant Neurologist. She was frank about the failures in communication in 2013 and 2014 and advised Mr Haigh of significant changes since Cannock Hospital was transferred to the Royal Wolverhampton Trust. However, also indicated in evidence that she is working regularly 7 days a week and the day before the inquest worked 14 hours (and again this was not unusual). These do appear to be excessive hours with an increased potential for fatal errors. | should be grateful if you could look at this. ah Mo, ° Ses Tint ine . = Aa ‘) ‘eon rg hws of utah Sms cearininmely VUVNUECT IT IS tingersicnn) Liia@L Lins raiurc i: Cures Action Taken The EC Directive on Working Time for Consultants was introduced in October 1998 and from this time onwards, all consultants are covered by the entitlements afforded by the Directive. In 1998, the Central Consultants and Specialists Committee (CCSC) of the British Medical Association and the NHS Executive negotiated a collective agreement regarding the application of the Directive for senior hospital doctors, which applied derogations to inflexible hourly, daily and weekly limits under regulation 21 and in their place established the right of senior hospital doctors to take compensatory rest where the limits were exceeded. These derogations were applied to ensure that continuing responsibility to patients was maintained and the necessary protection for senior hospital doctors under the directive was retained. This essentially means that the regulations relating to night working, daily rest, weekly rest and breaks at work do not apply to career grade hospital doctor, such as Dr Summers. However, under regulation 21, they are able to accrue compensatory rest for hours worked during rest breaks; this enables career grade doctors to continue to carry on their duties flexibly and professionally ensuring that they are able to maintain continuity of service. Dr Summers worked under this regime and her job plan reflected the above required criteria. Essentially, she was not working outside of the regulations. Nevertheless, | understand that the Medical Director and the Clinical Director for Neurosciences have reviewed fl HEE [0b plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, rem sessions will be reduced to allow her to have a better work life balance and since November , Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements. In addition to this not currently working in isolation at the County Hospital and has the support ofa second Consultant. She has also been encouraged to utilise the administrative support leila to her. Asa Neurosciences Directorate we are keen to provide the right working environment for and patient safety is very high on our priorities. | sincerely hope that this report provides H M Coroner, Mrs Haigh, with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mary Hyden seriously. Whilst it is understood that this failure in communication occurred prior to the merger of the University Hospital of North Staffordshire and Mid Staffordshire NHS Foundation Trust, the Trust strives to provide a high standard of care to all patients and | am grateful to you for raising these matters on this occasion so that we were able to review our processes post-merger. Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours sincerely MARK HACKETT 399 CHIEF EXECUTIVE at Mog, ° s aw inl ie tVVs Commend tb ererty 2 cameo May
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