Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0413, written 21 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 | 21 Oct 2015 |
|---|---|
| Reference | 2015-0413 |
| Deceased | Samantha Beach |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Gloucestershire Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
H M Senior Coroner for Gloucestershire
Ms Katy Skerrett
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive, Trust Headquarters, Gloucestershire Hospitals NHS Foundation Trust, 1
College Lawn, Cheltenham, Gloucestershire GL53 7AG
Hospital, Sandford Road, Cheltenham, Gloucestershire GL53 7AN
Head of Legal Services, Legal Services Department, Cheltenham General
1
CORONER
I am Katy Skerrett, Senior Coroner for Gloucestershire.
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 the 21st June 2013 the Acting Coroner for Gloucestershire commenced an investigation into
the death of Samantha Beach. The inquest was formally opened on the 25th June 2013, and I
held a pre inquest review on the 26th June 2014 (having been appointed as Senior Coroner for
Gloucestershire on the 1st June 2014). The investigation concluded at the end of the inquest on
the 8th-9th October 2015. The conclusion of the inquest was a narrative conclusion. The medical
cause of death was ruptured splenic artery aneurysm.
4
CIRCUMSTANCES OF THE DEATH
Sam was a healthy 25 year old young lady. She had given birth to two babies previously without
any problems. On the 10th June 2013 she developed severe chest pain within three hours of
giving birth to her third child. She also developed intermittent tachycardia. Her pain persisted
when she was discharged from hospital on the 12th June 2013. Whilst she was in hospital her
severe chest pain was not investigated appropriately. Sam made midwives and junior doctors
aware of her pain. Advice was not sought from more senior colleagues. Between the 13th – 15th
June her chest pain continued and she was seen at home by community midwives and an out of
hours GP. Sam was not readmitted to hospital. On the 17th June she attended the emergency
department with ongoing chest pain, but she was discharged again within three hours. Advice
from an obstetrician was not sought. On the 20th June 2013 she had further severe chest pain,
she fitted and then she collapsed. Whilst she was being transferred to hospital she had a cardiac
arrest. She was admitted to hospital in a state of cardiac arrest. Cardio-pulmonary resuscitation
was carried out. The clinicians considered the most likely diagnosis to be pulmonary embolism,
and therefore Sam was anticoagulated. However it soon became apparent that her abdomen
was swelling, and intra-abdominal bleeding was suspected. An emergency laparotomy was
carried out, and it was found that she had bleeding from a ruptured splenic artery aneurysm. A
splenectomy was carried out. Postoperatively her condition deteriorated. The clinicians could not
stabilize her coagulation. She suffered a further cardiac arrest on the morning of the 21st June
2013. She was pronounced deceased at 06.58 hours. If her severe chest pain had been
adequately investigated it is more probable than not that her splenic artery aneurysm would have
been detected. If detected, it is more probable than not that Sam could have undergone
successful operative repair.
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ
Tel 01452 305661 | Fax 01452 412618
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. –
(1) The clinical care provided to Sam in the obstetric department was not escalated
appropriately to more senior colleagues,
(2) When Sam was being cared for in the community, there was no process to ensure the
sharing of information or joining up of care between the midwives, out of hours, GP and
obstetric department.
(3) When Sam attended the Emergency Department as a post-natal patient (7 days post
partum) the obstetric department were not involved in her care.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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
4pm 17th December 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
partner of
, Iacopi-Palmer Solicitors (solicitors for
(1)
Sam), Spinnaker House, Spinnaker Road, Gloucester GL2 5FD
(2)
, mother of Sam,
I 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, about the
release or the publication of your response by the Chief Coroner.
9
Dated 21st October 2015
Signature_________________________
Ms K Skerrett
Senior Coroner for Gloucestershire
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ
Tel 01452 305661 | Fax 01452 412618
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