Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0263, written 9 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 | 9 Jul 2015 |
|---|---|
| Reference | 2015-0263 |
| Deceased | Toni Piel |
| Coroner | Matthew Cox |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Acute Hospitals NHS Trust |
| 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: REPORTTO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORTTO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENTTO: 1. Pennine Acute Hospitals NHS Trust 2. Department of Health CORONER I am Matthew Cox, Assistant Coronerforthe Coronerarea of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroner’s and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 1th2 February 2015 Catherine McKenna, Assistant Coroner, commenced an investigation into the death ofToni Piel. The investigation was concluded at the end of the Inquest on the 2th6 May 2015. The conclusion of the Inquest was that the deceased died on the 23 December 2014 at his home address, 65 Wood Park Court, Whitebank Road, Limeside, Oldham as a result of a head injury caused by a fall. The evidence did not disclose whether a head injury which occurred on 10 December 2014 and which resulted in treatment at The Royal Oldham Hospital or a separate unconnected injury caused his death, the medical cause ofdeath being: la) Intracranial Haemorrhage lb) Head Injury lc) Fall 4 CIRCUMSTANCES OF DEATH The deceased was born on 5th March 1949 and was 65 years old at the time of his death on 23 December 2014. On the 1th0 December 2014 the deceased suffered an injury to the back of his head in a fall at his home address. He was taken to the Royal Oldham Hospital by emergency ambulance. The ambulance records outline a possible recurrent fall with the fourth fall that day. The deceased stated that he had had approximately4 cans of lager. On arrival in the emergency department it was noted that the deceased had a laceration to the back of his head approximately 5 inches, that he drank most days and that there was the possibility of recurrentfalls. The injury was cleaned and closed with 4 sutures. The deceased was considered to be safe to be discharged home with head injury advice and wound care. On the 2rd3 December 2014 one of the deceased’s neighbours contacted the police as he was unable to make contact with the deceased. Entry to the deceased’s flat was forced and the deceased’s body was found lying on the floor by the bed fully clothed. A Post Mortem Examination was conducted by Consultant Histopathologist. He noted a large subdural haematoma in the middle and posterior regions of the brain and a prominent subarachnoid haemorrhage in both temporal lobes and cerebellum. He said the evidence was consistent with another injury suffered at The Royal Oldham Hospital 10 December 2014. In his opinion the possible explanations were that the fall which resulted in treatment at The Royal Oldham Hospital on 10 December 2014 had triggered a further fall which had led to his death or that he had suffered a fall which was not connected with the fall for which treatment was provided on 10 December 2014. 5 CORONER’S CONCERNS During the course ofthe 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: i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account. ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each ofyou respectively 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 3rd September 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 ChiefCoronerand to the following Interested Persons namely: I am also under a duty to send the ChiefCoroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. 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 ChiefCoroner. g Date: 9th July 2015 Signed: ‘M /
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 euinenel SWIA 2NS POCS 947712 Tel: 020 7210 4850 Mr M. Cox Assistant Coroner 03 SEP 2015 HM Coroner’s Court The Phoenix Centre L/Cpl Stephen Shaw MC Way Heywood OL10 1LR Ky C3. —— Thank you for your letter of 10" July 2015 following the inquest into the death of Toni Piel. I was very sorry to hear of Mr Piel’s death and wish to extend my sincere condolences to his family. Mr Piel died at his home address on 23" December 2014. He had earlier fallen at home on 10" December, suffering a head injury which resulted in an emergency admission to hospital. On that occasion his head wound had been sutured and he had been discharged home with head injury and wound care advice. Your concerns centre round the lack of adequate assessment of the risks to the patient when he was discharged home. You state that: e No assessment had been made which would have uncovered that there was no-one at home to observe the patient. You refer to NICE guidance issued in January 2014 which recommends home circumstances are taken into account. e No assessment of risk factors around discharge was documented in the deceased records. These are both operational matters for the trust involved. I note that your report has been sent to the Pennine Acute Hospitals NHS Trust. I understand that Pennine Acute has undertaken a review of this case which has resulted in actions to improve the management, supervision, assessment and discharge of head injury patients in their care. The Trust will provide you with full details in its response. Ata national level a network of fifteen Patient Safety Collaboratives, led by Academic Health Sciences Networks, has identified improving discharge from hospital and transfers and transitions of care as a priority. The initial focus of this work is on improving communication during discharge. As the programme of work develops, it is likely that further priorities will be identified. Work has also been done by the National Institute of Health and Care Excellence (NICE) to examine the issue of patients who fall in their own homes and the prevention of further falls. This has resulted in the publication of NICE’s Quality Standard, ‘Falls in older people: assessment after a fall and preventing further falls’, in March 2015. The Falls and Fragility Fracture National Audit Programme is a national clinical audit run by the Royal College of Physicians. It is designed to audit the care received by hospital patients who are vulnerable to falling or have been injured in a fall, and to facilitate quality improvement initiatives. Further information on this programme can be found at: The NICE guideline you reference appears to be Clinical Guidance 176 on Head Injury. This recommends that patients with a head injury should only be discharged when someone is at home to supervise the patient. The section on discharge and follow-up states: 1.9.5 All patients with any degree of head injury should only be transferred to their home if it is certain that there is somebody suitable at home to supervise the patient. Discharge patients with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible. 1.9.6 Patients admitted after a head injury may be discharged after resolution of all significant symptoms and signs providing they have suitable supervision arrangements at home. NICE guidance is not mandatory. However,practitioners are expected to take such guidance fully into accoiint. I am grateful to you for bringing the circumstances of Mr Piel’s death to my atteftjon and hope that you this reply helpful. [0 <™_ BEN GUMMER
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