Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0428, written 6 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 | 6 Nov 2015 |
|---|---|
| Reference | 2015-0428 |
| Deceased | Vera Williams |
| Coroner | Nicola Jones |
| Coroner area | North East and North Central Wales |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. CHIEF EXECUTIVE BETS! CADWALADR UNIVERSITY NHS TRUST
1 | CORONER
lam Nicola Jones, assistant coroner, for the coroner area of North East and North
Central Wales
2 | 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.
3 | INVESTIGATION and INQUEST
On 3 November 2014 | commenced an investigation into the death of Vera Hilda
Williams , aged 77. The investigation concluded at the end of the inquest on 18
September 2015. The conclusion of the inquest was ~ Medical Cause of death: - 1a.
Massive Gastrointestinal Tract Haemorrhage due to 1b. Oesophageal- Aortic Fistula due
to 1c. Oesophageal Rupture. Conclusion : Death was due to an accident.
4 | CIRCUMSTANCES OF THE DEATH
Mrs Williams attended the Emergency Department of Glan Clwyd Hospital on 10
October 2014 complaining of pain after eating toast. She was given pain killers and
observed to be swallowing. Mrs Williams was examined . Upon a review the pain had
been resolved and she was sent home. The Emergency Department doctor took the
view that there had been an obstruction which had resolved itself,
Mrs Williams returned to the Emergency Department on 23 October 2014 complaining
of pain in the left side of her face and back of her neck. Usual Observations and bloods
taken, Her chest was examined but not x rayed. Mrs Williams was discharged home at
02.20 hours with oral antibiotics and painkillers. She was suspected of having a mild
upper respiratory tract or urinary infection.
Mrs Williams attended the Emergency Department at 19.09 after calling an ambulance
at 17.46 on 24 October 2015. She had coughed and vomited a blood clot. She was
generally unwell. At 16.00 hours on 25 October 2015 after other investigations including
Chest Xray, Bloods, General observations and physical examination , a CT scan
revealed that Mrs Williams had a ruptured aorta . It is probable that this was caused by
swallowing the toast which was complained of on her first visit to the emergency
Department on 10 October 2104. Surgical intervention was not appropriate for Mrs
Williams and she died on 28 October 2015 at Glan Clwyd Hospital.
The presentation for Mrs Williams was different on the three separate occasions that she
attended the Emergency Department. The Doctors on call had to rely upon Mrs
Williams to tell them that she had been admitted previously and what had occurred on
those previous visits to the Emergency Department. In this case it was only the CT
Scan which showed the Oesophageal Rupture. The presentation of Mrs Williams on the
10 and 24 th October was not such that a CT Scan could reasonably be expected to be
carried out on the examination and presentation of Mrs Williams on those occasions.
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 foliows. —
(1) Doctors and staff in the Emergency Department do not have a DIGITAL
CENTRAL RECORD ( ie on a computer database) of who has passed through
the Emergency Department , their symptoms and what treatment they have
received.
(2 )Doctors must rely upon the patient telling them what has happened and then there is
a delay whilst previous paper notes are located and retrieved. This lack of easy and
swift access to accurate information is fraught with risks for patients and clinicians in the
arena of Emergency medicine where time is of the essence in coming to a diagnosis.
An accurate history is an essential tool in coming to that diagnosis. Any delay can have
potentially fatal consequences for a patient.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation has 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 8" January 2016. |, 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
5s TTT 2: of Nes Wiliams
{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.
[DATE] [SIGNED BY ¢
6" November 2015 Nicola Jo
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