Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0458, written 30 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 | 30 Sep 2015 |
|---|---|
| Reference | 2015-0458 |
| Deceased | Jean Hannon |
| Coroner | Michael Singleton |
| Coroner area | Blackburn, Hyndburn and Ribble Valley |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Lancashire Healthcare 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer East Lancashire Healthcare NHS Trust Trust Headquarters The Royal Blackburn Hospital Haslingden Road Blackburn BB2 3HH CORONER I am Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn & Ribble Valley. 2 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. 3 INVESTIGATION and INQUEST On the 23% December 2014 I commenced an Investigation into the death of Jean Helen Hannon aged 75. The investigation concluded at the end of the Inquest which was held on the 23 September 2015. The conclusion of the Inquest was that Jean Helen Hannon died from a rare but recognised complication of surgical treatment. CIRCUMSTANCES OF THE DEATH On the 27" August 2011 Jean Hannon who was suffering from altered sensations in her hands due to degenerative changes in her cervical spine underwent a laminectomy at the Royal Preston Hospital. As a consequence of the procedure Jean Hannon became quadriplegic and developed autonomic dysreflexia. Subsequently she had a number of admissions to the Royal Blackburn Hospital but thediagnosis of autonomic dysreflexia was not sufficiently highlighted in the medical record such that when she was admitted to the Royal Blackburn Hospital on the 19" December 2014 with a history of not having opened her bowels for some 13 days the consultant physician (was unaware of the previous diagnosis of autonomic dysreflexia. CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving arise to concern. In my opinion there is a risk that further deaths will occur unless action is taken. In the circumstances it is my duty to report to you the MATTER OF . CONCERN is as follows: - H That the medical records retained at the Royal Blackburn Hospital failed to sufficiently highlight the previous diagnosis of a condition that is potentially life threatening. 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 25" November 2015. I, the Coroner, may extend this 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 person, namely: 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. 30 September 2015 Signed by: ™) aDeastbiiinscnsagesssssasbenscenasarsronces H M Senior Coroner for Blackburn, Hyndburn & Ribble Valley i
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.
East Lancashire Hospitals INHS) NHS Trust Enquiries to PY Quality and Safety Unit Telephone 01254 733361 Park View Offices Ext 83361 Royal Blackburn Hospital Fax Haslingden Road Email Blackburn BB2 3HH 24" November 2015 PRIVATE & CONFIDENTIAL Mr MJH Singleton HM Coroner Fieldings/Porter Solicitors 7 Richmond Terrace BLACKBURN BB1 7BB Dear Mr Singleton Regulation 28 Report to Prevent Future Deaths: Jean Helen Hannon (dated 30/9/15) | am writing in response to the regulation 28 report received by East Lancs Hospitals NHS Trust in relation to the above deceased patient, which was forwarded to me. A review of Mrs Hannon’s medical records has been undertaken in light of your report, this was conducted by Consultant Physician. On review of the case-notes it is noted that Mrs Hannon had a spinal cord injury following a laminectomy in 2011, following which she suffered with quadriplegia. It is the belief of EE tht Jean Hannon did not have autonomic dysreflexia, and that there is no substantiating evidence in the case-note to say that she did. The only time autonomic dysreflexia was mentioned was during a case conference on the 12" March 2012 where the family of Mrs Hannon were present and no physician was present. At the case conference the condition was mentioned by Mrs Hannon’s daughter where she asked what would be the implications on her mother's care of autonomic dysreflexia. The documented agreed plan following the case conference did not mention this condition, and nor does it appear in the records to have been mentioned to the ward staff afterwards who would have been able to discuss it in more detail. If this opportunity had arisen then the staff would have been able to explain that there was no evidence of autonomic dysreflexia. It is believed that Mrs Hannon suffered a condition more accurately termed autonomic instability. Autonomic dysreflexia syndrome differs significantly from autonomic instability, with this latter diagnosis being a common finding in patients who have had spinal cord injury. Safe Personal Effective East Lancashire Hospitals INHS NHS Trust Dr Wilson has noted that Mrs Hannon’s GP does not reference the condition as a past medical history during admissions to Royal Blackburn Hospital and so adding to our view that this was not a confirmed and actual working diagnosis. Of greater concern to us is the issue relating to the capture of chronic and on-going conditions for patients presenting urgently to our services. In order that clinical staff treating patients are fully aware of such conditions we have we have undertaken a number of actions: 1. The Trust now has access to a case summary from the patients GP notes via an electronic system called ‘EMIS web’. This means that a printed summary of the case record is included as part of the patients case notes for every urgent and emergency admission. For planned admissions this information is gathered during the pre-admission processes. These arrangements have now been in place since April 2015. 2, ii a consultant geriatrician, is piloting the use of daily problem lists as a technique for documenting on-going concerns during ward rounds and daily assessments. This has been used in other hospitals specifically to address the issue of relevant clinical information not being passed on. This is currently in the pilot phase and will be rolled out to other areas after evaluation. | hope that this clarifies the clinical confusion and also our response to the wider issue of the capture of important clinical information. If you feel that there is anything more we can do in this instance then please do not hesitate to get in touch with me. Kind regards. Yours sincerely Deputy Medical Director (Quality, Safety and Workforce Development/Education) Consultant Anaesthetics and Critical Care Medicine Safe Personal Effective
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