Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0450, written 23 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 | 23 Oct 2015 |
|---|---|
| Reference | 2015-0450 |
| Deceased | Margaret Ferry |
| Coroner | Karin Welsh |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | City Hospitals Sunderland NHS Foundation Trust · County Durham and Darlington NHS Foundation 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.
Derek Winter DL Senior Coroner for the City of Sunderland LL REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Ms Sue Jacques Chief Executive Officer County Durham & Darlington NHS Foundation Trust Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington DL3 6HX 1 CORONER [am Karin Welsh, Assistant Coroner for the City of Sunderland. CORONER’S LEGAL POWERS NO 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. http://www Jegislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST ies) On 14" May 2015 I commenced an investigation into the death of Margaret Anne Ferry, aged 66. The investigation concluded at the end of the Inquest on 20" October 2015. The conclusion of the Inquest was that Margaret died as a result of the progression of a naturally occurring disease process but opportunities to ameliorate that process were lost as a consequence of a lack of communication. The medical cause of death was: - la Bronchopneumonia Ib Necrotising Fasciitis and II Diabetes Mellitus; Raised Body Mass Index 4 CIRCUMSTANCES OF THE DEATH Margaret had a number of underlying health issues and was admitted to Sunderland Royal Hospital on 8" January 2015. She underwent a planned amputation of her left 5" toe on 11" January. Thereafter she developed a deterioration to her skin integrity particularly around her abdomen and thighs. On 6" March a referral was made to the plastic surgery team at University Hospital of North Durham. Their role was to provide advice to the treating doctors in Sunderland. There was no clear understanding in each hospital of the role of the other in Margaret’s care. There was no clear understanding of the different practices and procedures in each hospital and the impact this would have on Margaret. There was inadequate Civic Centre, Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner communication, both written and oral, between the various doctors involved in Margaret’s care. Although Margaret was seen by a number of health professionals, including doctors, there was a lack of leadership, meaning that there was no cohesive treatment plan. On 22"! April 2015 Margaret underwent a debridement procedure which, although in itself successful, the missed earlier opportunities meant that Margaret’s underlying health problems had been exacerbated and she died on 12'" May 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: — 1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred. 2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - e City Hospitals Sunderland NHS Foundation Trust and their Solicitors e Family e CQC 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. Dated this 23" day of October 2015 Signature ! Assistant Coroner for the City of Sundetland
Derek Winter DL Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Mr Ken W Bremner Chief Executive City Hospitals Sunderland NHS Foundation Trust Sunderland Royal Hospital Kayll Road Sunderland SR4 7TP CORONER I am Karin Welsh, Assistant Coroner for the City of Sunderland. 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. http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation. gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 14" May 2015 I commenced an investigation into the death of Margaret Anne Ferry, aged 66. The investigation concluded at the end of the Inquest on 20" October 2015. The conclusion of the Inquest was that Margaret died as a result of the progression of a naturally occurring disease process but opportunities to ameliorate that process were lost as a consequence of a lack of communication. The medical cause of death was: - la Bronchopneumonia Ib Necrotising Fasciitis and I] Diabetes Mellitus; Raised Body Mass Index CIRCUMSTANCES OF THE DEATH Margaret had a number of underlying health issues and was admitted to Sunderland Royal Hospital on 8" January 2015. She underwent a planned amputation of her left 5"" toe on 11" January. Thereafter she developed a deterioration to her skin integrity particularly around her abdomen and thighs. On 6" March a referral was made to the plastic surgery team at University Hospital of North Durham. Their role was to provide advice to the treating doctors in Sunderland. There was no clear understanding in each hospital of the role of the other in Margaret’s care. There was no clear understanding of the different practices and procedures in each hospital and the impact this would have on Margaret. There was inadequate communication, both written and oral, between the various doctors involved in Civic Centre, Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 | Fax 0191 5537803. | DX 60729 Sunderland www.sunderland.gov.uk/coroner Margaret’s care. Although Margaret was seen by a number of health professionals, including doctors, there was a lack of leadership, meaning that there was no cohesive treatment plan. On 22" April 2015 Margaret underwent a debridement procedure which, although in itself successful, the missed earlier opportunities meant that Margaret’s underlying health problems had been exacerbated and she died on 12" May 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: — 1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred. 2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - e County Durham and Darlington NHS Foundation Trust and their Solicitors and Counsel e Family e CQC Tam 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. Dated this 23" day of October 2015 Signature Lou TNA Assistant Coroner for the City of Sunderland
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.
Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX e-mail: Our Ref: SJ/bc/KWelsh 17th December 2015 Karin Welsh Assistant Coroner for City of Sunderland Civic Centre Burdon Road Sunderland SR2 7DN Regulation 28 Report to prevent future deaths Dear Karin Please see the response from the Trust, County Durham and Darlington Foundation Trust, detailing the actions that have been taken following the concerns that you raised after the inquest held for the late Mrs Margaret Anne Kelly. In your correspondence you raised two main issues of concern:- 1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred. 2. Evidence was given that there were poor levels of communication both direct and indirect between medical and professionals at each trust and poor understanding of each other’s differing practices and procedures. We have recognised that there were significant gaps in the provision of services to Margaret therefore, Anne Ferry, City Hospitals Sunderland, and the Trust have worked closely with our colleagues at City Hospital Sunderland to address the issues raised. In collaboration we have developed a new standing operational procedure to provide a comprehensive approach to inter organisational referrals for plastic surgery opinions. The standard operating procedure provides a process to ensure that the referral is clearly documented; that a suitable response is provided within clearly defined timescales, and that it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. I have included this for your information. www.cddft.nhs.uk Chief Executive. Darlington Memorial Hospital, Hollyhurst Road, Darlington, County Durham DL3 6HX Please don’t hesitate to contact me if you require any further on this issue Yours sincerely Sue Jacques CHIEF EXECUTIVE cc. Ken Bremner www.cddft.nhs.uk Chief Executive. Darlington Memorial Hospital, Hollyhurst Road, Darlington, County Durham DL3 6HX
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