Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0436, written 16 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 | 16 Nov 2015 |
|---|---|
| Reference | 2015-0436 |
| Deceased | Christine McNamara |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Maidstone and Tunbridge Wells NHS Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Maidstone & Tunbridge Wells NHS Trust 1 CORONER | am Patricia Harding, senior coroner, for the coroner area of Mid Kent & Medway 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. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On 6" March 2015 | commenced an investigation into the death of Christine McNamara. The investigation concluded at the end of the inquest on 11"" November 2015. The conclusion of the inquest was that Christine McNamara died on 27" February 2015 at Maidstone Hospital as a consequence of a complication of an elective retrograde cholangiopancreatography (sepsis following a lower bile duct perforation). 4 | CIRCUMSTANCES OF THE DEATH Christine McNamara was admitted to Maidstone Hospital on 25" February 2015 for an ERCP. Approximately 2 hours after the procedure a doctor noted symptoms suggestive of a bowel perforation. She was managed conservatively. A CT scan conducted 10 % hours later confirmed a perforation. When her condition deteriorated on the evening of the 26" February she underwent a laparotomy which did not identify the perforation, but a washout and gastro-jejunostomy were performed. She deteriorated further and died. | have provided my findings to the Trust concerned in writing 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) It was established during the inquest that here was no pathway or guideline in place for post ERCP patients who develop complications (2)Out of hours radiography can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 1 4 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 | 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] lot, Ny } 1 201 SIGNED BY ee Piety
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.
Maidstone and Tunbridge Wells NHS] NHS Trust 15" February 2016 Glenn Douglas Chief Executive Private & Confidential Maidstone & Tunbridge Wells NHS Trust Maidstone Hospital Ms Patricia Harding Hermitage Lane The Coroner's Office Maidstone Archbishops Palace ME16 9QQ Mill Street Maidstone ME15 6YE Dear Ms Harding Regulation 28 Report to Prevent Future Deaths following the inquest of Christine McNamara who died at Maidstone Hospital on 27 February 2015. | am writing to respond to the concerns you raised during your investigation into the death of Christine McNamara, and to explain the actions that Maidstone and Tunbridge Wells NHS Trust has taken in order to address those concerns. 1) It was established during the inquest that here (sic) was no pathway or guideline in place for post ERCP patients who develop complications Our Medical Director discussed the issues raised in your report with representatives from the medical and surgical teams, and a new pathway (The Pathway for suspected post-endoscopy complication, perforation or leak) was devised to provide clear guidance to all staff on how to manage patients who have undergone endoscopic surgery. The pathway was implemented in January 2016, and a copy of the pathway is enclosed for your information. We are committed to ensuring that this pathway successfully addresses the potential issues regarding the appropriate escalation of unwell patients at all times — wherever they are within the Trust, and on whichever site. To ensure that the pathway adequately addresses the issues as intended, we will allow an initial period of 6 months for the pathway to become embedded, before conducting a full review (scheduled for October 2016) to consider whether any further clarity is required by our staff. As the pathway is already in effect, we are confident that it addresses the concern you raised. 2) Out of hours radiology can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells Surgical consultant cover at Maidstone Hospital | want to start by assuring you that there is always a consultant general surgeon on call at all times and they can always be accessed by contacting switchboard — in the event a junior member of staff does not know who is on call, switchboard has a list and can direct them as appropriate. Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000 Fax: 01622 226416 Maidstone and Tunbridge Wells INHS NHS Trust During the week the consultant on call predominantly covers the Tunbridge Wells Hospital, which is the acute site with emergency admissions and an Associate Specialist (senior surgeon) covers the Maidstone Hospital site out of hours, but with access at all times to the consultant on call. Consultant to consultant radiology referrals out of hours | appreciate that, taken out of context, the need for a consultant to consultant referral for radiology out of hours can seem onerous, but | want to assure you that there are sound clinical reasons underpinning the policy. Out of hours, junior doctors manage the immediate treatment of patients — escalating patients for additional investigations and/or procedures where necessary. In the past we have had instances where junior doctors were escalating the treatment of unwell/seriously unwell patients without consultant input. This resulted in consultants not being adequately involved in the treatment decisions of their patients, so to resolve this we introduced the consultant to consultant referral — thereby ensuring there is always adequate consideration of all treatment options. Ac explained at the inquest hearing, although CT scans are helpful in diagnosing patients they are by no means the only diagnostic tool, and where possible alternatives (which do not expose patients to potentially harmful levels of radiation) should always be considered. Where necessary, based on clinical presentation, we will always provide a CT scan for a patient who requires one - including out of hours. Thank you for taking the time to bring your concerns to my attention. At Maidstone and Tunbridge Wells NHS Trust we always welcome the opportunity to learn from the experiences of our patients, and | trust that this response provides you with sufficient assurance that we have acted decisively. Yours sincerely Cu Ma Glenn Douglas Chief Executive Enc: The Pathway for suspected post-endoscopy complication, perforation or leak Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000 Fax: 01622 226416
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