Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0400, written 7 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2015 |
|---|---|
| Reference | 2015-0400 |
| Deceased | Geoffrey Parry |
| Coroner | Andrew Barkley |
| Coroner area | Cardiff and the Vale of Glamorgan |
| 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.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Adarn Cairns Chief Executive, Cardiff and Vale University Health Board, UHW Heath Park, Cardiff CFi4 4XW CORONER lam Andrew Barkley, Senior Coroner for Cardiff and the Vale of Glamorgan area 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. INVESTIGATION and INQUEST One" July 2015 | commenced an investigation into the death of f Geoffrey Parry, aged 74. The investigation concluded at the end of an inquest on 30" September 2015, The medical cause of death was 1a pneumonia, 1b locally advanced bladder cancer (operated). | returned a narrative conclusion “Geoffrey Colin Parry died from the effects of pneumonia which he contracted having undergone major surgery for bladder cancer.” CIRCUMSTANCES OF THE DEATH Mr Parry had been complaining of urinary symptoms for in excess of twelve months, was referred to a urologist at the University Hospital of Wales and was diagnosed with suffering from an aggressive bladder cancer. He elected to undergo surgery for the removal of the tumour which took place on 1" May 2015. During the lengthy and complex surgery he developed several episodes of abnormal heart rhythm which caused the surgery to be suspended. The surgery was eventually completed, successfully, and he was taken to the intensive care unit for further support. He made steady progress before developing infection which turned into pneumonia from which he passed away on 29" June 2015. 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. ~ During the evidence it transpired that an ECG test which was undertaken on 21* April 2015 was not available to the reviewing consultant anaesthetists prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient's medical notes. in this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened. The evidence at the hearing suggested that this was a not uncommon problem. In this case the unavailability of the scan was not in any way causative of Mr Parry's death but could have been. During the evidence it became clear that whilst in intensive care an intravenous line administering noradrenaline was disconnected from Mr Parry which caused his blood pressure fo drop significantly to the point of requiring cardiopulmonary resuscitation. The evidence indicated that it was likely this line was disconnected by one of the attending nurses by “accident” as the line was not labelled as best practise dictates. The evidence revealed that there were no labels for the line to be labelled with and there is no protocol requiring intravenous lines to be labelled to ensure that they are not accidentally disconnected, for example, when other drugs are administered. The evidence clearly showed that if the noradrenaline line had been clearly labelled it would not have been disconnected as the nurses and medical team within the critical care unit would fully appreciate the implication to the patient. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the Chief Executive of the Health Board has 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 27" November 2015. |, the coroner, may extend that 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. Mr Drakeford AM, Minister for Health, Welsh Government lam 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. DATE: 7 October 2015 iFolnbt,) Senior Coroner a .
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.
Ysbyty Athrofaol Cymru University Hospital of Wales UHEB Headquarters d Bwrdd lechyd Prifysgol Caerdydd a’r Fro University Health Board — Cardiff, CFIl4d 4xW Caerdydd, CF14 4X W Eich cyf/Your ref: Ein cyf/Our ref; AC-ns-31-5237 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 02920 745681 Professor Adam Cairns Chief Executive 26 November 2015 Private and Confidential Mr A Barkley Senior Coroner Coroner’s Court Central Police station Cathays Park Cardiff CF10 3NN Dear Mr Barkley Regulation 28 report — Mr Geoffrey Parry (died 29"" June 2015) Thank you for your letter dated 7 October 2015, which was received by the Health Board on 8 October 2015. | have reviewed the points raised within the Regulation 28 report regarding the sad death of Mr Parry. My response has been informed by senior clinicians responsible for the clinical care provided to Mr Parry and other appropriate colleagues. | recognise that this will have been a particularly difficult time for Mr Parry's family and would wish to offer my sincere condolences on behalf of the University Health Board. For ease of reference, | will respond to each of the matters of concern you have raised in turn. e An ECG test undertaken on 21 April 2015 was not available to the reviewing consultant anaesthetist prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient’s medical notes. In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened. The University Health Board has taken the opportunity to completely review the systems and processes in place for the storage of ECG investigations. The Cardiac Physiology Department hosts a system called MUSE which allows for electronic storage of ECGs. Currently, a limited number of departments utilise this system. s Pa AY fo 2 s Bwrdd lechyd Prifysgol Caerdydd a'r Fro yay enw gweithredol Bwyrdd Lechyd Lieol Prifysgol Caerdydd a'r Fro a Cardiff and Vale University Health Board is the operational neme of Cardiff and Vale University Local Health Board age “4 S Cardiff and Vale Heath Park Parc Y Mynydd Bychan An upgrade to the MUSE software is anticipated to be released shortly. When this occurs, it will allow for connectivity between the MUSE system and Clinical Portal. The Clinical Portal system records inpatient and outpatient activity; test results; clinical correspondence arnongst other patient-related activity. Clinical Portai is widely accessible to clinical staff. In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including: e anECG training needs analysis; e improved identification of staff members undertaking ECGs on patients e review of ECG machines suitable for purchase to ensure they can connect to the MUSE system and improve patient identification on ECGs undertaken; e review of ECG machine maintenance with the Clinical Engineering department and e a review of the use of the MUSE system to ensure the Cardiac Physiology Department and infrastructure in place to support the MUSE system can sustain an increase in ECG activity using the software. In order to progress this work over the coming weeks, a paper will be presented to the Health Systems Management Board in December 2015. e An intravenous line administering noradrenaline was accidentally disconnected from Mr Parry causing his blood pressure to drop significantly to the point of requiring cardiopulmonary resuscitation. An improvement plan has been put in place to strengthen intravenous infusion labelling practice and is being implemented and monitored by the Critical Care department. An audit of current practice undertaken in November 2015 demonstrates satisfactory compliance but with further room for improvement. A standard operating procedure regarding the management of intravenous infusion line is now in development. Appropriate moisture resistant stickers have been sourced to improve line labelling procedures. The Practice Educator team have implemented training sessions and posters to highlight the incident and arising issues to staff. Arrangements to share the learning from this incident are in place for the Cardiothoracic and Critical Care Directorate in January 2016 and for the Specialist Services Clinical Board in February 2016. Your findings at Mr Parry’s inquest are of relevance to all Clinical Boards in the University Health Board. A copy of your Regulation 28 report and my response will be shared with all Clinical Boards with the intention that all clinical areas will review the actions undertaken to date and assess areas of clinical risk in their directorates to minimise risk of recurrence of the matters of concern. | hope that the information set out in this letter provides you with the assurance that the Health Board has fully considered the issues raised as a consequence of the inquest into Mr Parry's death and your letter of 7 October 2015, and has taken appropriate action in response. oat Se Bwrdd Iechyd Prifysgol Caerdydd a'r Fro yw enw gweithredel Bxyrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro Cardiff and Vafe University Health Board is the operational name of Cardiff and Vale University Local Health Board Dsays 80, Sp <7 (VAS S < SY Yours sincerely lie An— Professor Adam Cairns Chief Executive Abo, 208, « eS Peo y n Bwidd Iechyd Prifysgol Caerdydd a’r Fro yw envy gweithredol Bwwyrdd lechyd Lleol Prifysgol Caerdydd a'r Fro ‘ Cardiff and Vate University Health Board is the operational name of Cardiff and Vale University Local Health Board sage
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