Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0426, written 4 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2015 |
|---|---|
| Reference | 2015-0426 |
| Deceased | Michael Logue |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Community health care and emergency services 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. The Practice manager at Central Surgery CORONER | am Louise Hunt Senior Coroner for Birmingham and Solihull 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 On 25/06/2015 | commenced an investigation into the death of Michael Patrick Joseph LOGUE. The investigation concluded at the end of the inquest 2nd November 2015. The conclusion of the inquest was that the deceased died from recognised complications following a liver transplant. CIRCUMSTANCES OF THE DEATH The deceased had a liver transplant on 03/07/12. He developed a biliary stricture after the operation. He was admitted for biliary reconstruction surgery on 29/05/15. He went home on 01/06/15. He requested a home visit from his GP as he was complaining of pain on 03/06/15. The GP did not carry out a physical examination. He requested a further home visit by another GP on 09/06/15 who carried out a physical examination and diagnosed a wound infection. He was admitted to University Hospital Coventry and Warwickshire on 11/06/15 where he died a few hours later. A post mortem examination confirmed that he died from sepsis from a liver abscess following the biliary tree reconstruction. 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 GP failed to carry out any physical examination of the patient during a home visit on 03/06/15. Mr Logue was complaining of not feeling at all well and of pain and was 5 days post biliary reconstruction surgery. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you BB 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 30" December 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 The family and NHS England. 1am 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. 04/11/2015 Louise Hunt Senior Coroner Birmingham & Solihull District ##DW<<corAddress>> ‘Tel ##DW<<corTel>> | Fax ##DW<<corFax>>
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.
J.Cotterill E.Eedle D.Black Central Surgery yaa J.Barhey L.Armstrong CORPORATION STREET, RUGBY, CV21 3SP_ Tel 01788 524366 AWinter ALSO AT BILTON GREEN, RUGBY, CV22 7LY Tel: 01788 818939 B.Sriram Fax01788 547693 T.Rayment Z Hughes L Marshall T Atwal R Kalyani Dear Mrs Hunt, As requested | have reflected on the content of your report aimed at preventing future deaths. Central Surgery has discussed the case as a significant event as well. | appreciate that you are concerned to prevent future deaths. On reflection | believe in the case of Mr Logue the standard of my medical care, both in history taking and examination fell short of my usual practice. | have learned to be extra vigilant for post- operative complications and not to rely solely on the history given by the patient. or just on their general appearance. | would like to reassure you that in the past year | have successfully managed two cases - of biliary sepsis. | am pleased to say that | received positive comments from both relatives and colleagues in relation to my care for these patients. | am, if required, able to provide you with documentary evidence to support this statement. The care of Mr Logue was discussed at a significant event analysis meeting at Central Surgery. My GP colleagues did not think that a routine examination of every post- operative patient was indicated and that use of a sepsis check list was not routine practice. However, it was agreed that in future it would be prudent to undertake a more detailed examination and to accurately and fully record the findings in any consultation. Some of the GPs in the practice have surgical training and considered that the hospital could be more proactive in contacting patients at home after major surgery. | have spoken to the hepatobiliary co-ordinator at University Hospitals, Birmingham and was advised that following a liver transplant, patients are contacted at home within one week of surgery, but that this is not the case following bile duct surgery. | am aware that following cardiac surgery in University Hospital, Coventry every patient is contacted by the liaison nurse within a few days following discharge. Following the significant event meeting | am now, on behalf of the practice, in the process of contacting Professor Muiesan to discuss with him how communication in relation to postoperative care can be improved. Yours sincerely, ae Dr Emma Eedle J.Cotterill E.Eedle D.Black Central Surgery Diack J.Barhey L.Armstrong CORPORATION STREET, RUGBY, CV21 3SP_ Tel: 01788 524366 AWinter ALSO AT BILTON GREEN. RUGBY. CV22 7LY Tel: 01788 818939 B.Sriram T.Rayment Z. Hughes L. Marshall Dr T Atwal 23" December 2015. Mrs L Hunt, Senior Coroner for Birmingham and Solihull Areas, r 50 Newton Street, | RECEIW Birmingham, B4 6NE. f JAN Our ref: RB/2015/12-1 Your Ref: 002189/2015 ( T ORGAN/AS) — Dear Mrs Hunt, Re: Report on Preventing Future Deaths (Mr Michael Patrick Joseph Logue) . Your report and the concerns that you raised have been reviewed under our clinical review Process. As is our normal Procedure your concerns were raised as a Significant Event. The Practice has carried out a significant event review. The review noted that during the home visit Dr Eedle did not carry out a physical examination of the patient. During the review process it was noted that a physical examination of post-operative patients was not always indicated and that the use of a sepsis check list was not routine practice. The review benefited from input from GP Colleagues who are qualified Surgeons and or have surgical experience. As such it was also observed that the hospital did not appear to have been proactive in its follow-up care. Following the Significant event review the following actions were agreed for immediate implementation: 1.0 That the event be shared with all clinicians to improve their work practices. 2.0 That in future more detailed examination of the patient in such cases should be carried out and the results of which should be fully recorded in the patient notes. 3.0 Dr Eedle to contact the Hospital to see how communication can be improved to support the care of Post-Operative patients. If you require any additional information please do not hesitate to contact me. tooo R St Claire-Barrass. Practice Manager.
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