Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0457, written 29 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2015 |
|---|---|
| Reference | 2015-0457 |
| Deceased | Parv Patel |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
. 1 North London Coroners Court, Her Majesty's Coroner for the 29 Wood Street, ey Northern District of Greater London —_Bamet ENS 48 ae (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 the 19" day of November 2014 | opened an investigation touching the death of Parv Patel , 4 years old. The inquest concluded on the 14" September 2015 The conclusion of the inquest was “Narrative”, the medical case of death was ‘1a Influenza A infection 4 | CIRCUMSTANCES OF THE DEATH Parv Patel ,aged 4 years old, was taken to hospital on the 28" November 2014 suffering with an infection. By 02.00hrs the following morning he had become seriously unwell with symptoms of heart failure as a part of a septic picture, the fact that he was experiencing symptoms of heart failure at this time was not recognized until much later the following day at 09.45 hrs. A doctor decided reasonably, to intubate Parv which, due to the development of a cardiac tamponade, precipitated his cardiac arrest and death at 13.25hrs_ in the early afternoon. Parv Patel died following intubation having suffered a rare complication of flu. 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. — That PEWS scores do not reflect current research into child illness. Her Majesty's Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) And that the Pews scores may tend to act to distract the doctors away from the fact that despite a low PEWS score a child might be seriously ill ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR 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 Wednesday 25" November 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- Representatives of the family and the Hospital Trust 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. 29™ September 2015
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.
From Jane Ellison MP Parliamentary Under Secretary of State for Public Health Mr Andrew Walker HM Coroner for the Northern District of Greater London North London Coroners Court 29 Wood Street Barnet EN5 4BE Richmond House 79 Whitehall London SW1A 2NS Tel: 020 7210 4850 Dear Mr Walker Thank you for your letter to Jeremy Hunt about the death of Parv Patel. I am responding on his behalf as the Minister with responsibility for Child Health. I was very sorry to hear of Parv’s death. Your report gives an overview of the circumstances surrounding Parv’s admission to hospital and noted the following concerns; • Paediatric early warning system (PEWS) scores do not reflect current research into child illness; and • PEWS scores may tend to act to distract doctors away from the fact that, despite a low PEWS score a child may be seriously ill. NHS England are continuing to work towards developing a consensus view on a paediatric early warning system. There is at present no nationally recommended PEWS score. The complexities of developing a single score are a challenge. It would have to reflect the differing needs and requirements of all children from infants to teenagers, with a range of greatly different underlying healthcare conditions. Developing such a score is the subject of current research funded by the National Institute for Health Research. NHS England, with the Royal College of Paediatrics and Child Health (RCPCH), is now examining the elements of a framework for the recognition and response to children at risk of deterioration, which would be a PEWS system .This system would include such aspects as a structured communication, escalation to senior staff and review and would not remove the professional clinical view or indeed the parental or carers views or concerns. It should also consider the wider elements of clinical handover and briefings. It is recognised that a clinician could be distracted from identifying a child’s deterioration if only the score is considered in isolation from other factors. I have sent your report on to Carol Ewing, Vice President of Health Policy at RCPCH: and to Peter Lachman, the Deputy Medical Director for Safety at Great Ormond St and clinical lead for the RCPCH-led Situation Awareness For Everyone project, to inform their work in this area. I hope that this information is helpful and I thank you for bringing the circumstances of Parv’s very sad death to our attention. Yours sincerely, JANE ELLISON
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