Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0017, written 20 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jan 2016 |
|---|---|
| Reference | 2016-0017 |
| Deceased | Steven Rogers |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Stockport NHS Foundation Trust: 1 CORONER lam John Pollard, senior coroner, for the coroner area of South Manchester 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 27" August 2015 | commenced an investigation into the death of Steven Leslie Rogers dob 15"" July 1969. The investigation concluded on the 13" January 2016 and the conclusion was one of Natural Causes. The medical cause of death was 1a Diabetic Keto-acidosis 1b Type 1 Diabetes Mellitus. + 4 | CIRCUMSTANCES OF THE DEATH This man was admitted to Stepping Hill Hospital on the 20" August 2015 via the E.D. at 11.21am: he had been sent by his GP who had noted reduced consciousness and confusion in a man who was known to be a fairly unstable Type 1 Diabetic. He was admitted to the wards and overnight he was to have, inter alia, his long acting Levemir insulin. This was accidentally omitted. The following day he was discharged as medically fit, by one of the consultants who had never seen the patient, and he was found dead at home two days later, having died from Diabetic Keto-acidosis. 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. The doctor who discharged the patient from the hospital as being “medically fit for discharge” did so without ever seeing the patient. In his statement to the inquest he says “I am afraid | have never seen Mr Rogers......... he was seen by two consultant colleagues........... | was asked if he could go home by one of the nurses.....was shown the notes . asked the nurse to follow the team’s pre-arranged plan i.e. to discharge the patient. It is noted that Mr Rogers went home by bus”. The fact that a doctor not only discharges a patient in this way but also has no compunction in saying that he has done so in a statement to a Coroner, suggests a fundamental lack of understanding as to the importance of ensuring that all factors are in place for discharge, including medical and social issues. 2. During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin. This was then given later but this meant that his regime had been altered and he would have to re-set the regime at home. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 16" March 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 co) to the Chief Coroner and to the following Interested Persons namel (sister of the deceased and his next-of-kin). | have also sent it to CQC an , who may find it useful or of interest. | 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 intereskYou 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. 20.1.16 John Pollard, HM Senior Coroner
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.
Stockport NHS) NHS Foundation Trust Oak House Stepping Hill Hospital Poplar Grove . Stockport Our ref. SLR - 133104 SK2 7JE Your ref. JSP/KN/02688-2014 = Telephone: 0161 483 1010 RECE] VED Fax: 0161 487 3341 Direct fine: 0161 419 5444 1 April 2016 ~6 APR 2016 Ena ER H. M. Coroner Greater Manchester South District Coroner’s Court Mount Tabor Mottram Street Stockport SK1 3PA Dear Mr Pollard Re: Steven Leslie ROGERS (Deceased) | am writing in response to your regulation 28 report dated 20 January 2016 in which you write following the inquest into the death of the above named person. | am grateful to you for highlighting your concerns and for providing me with an opportunity to respond. | shall address each of your concerns in the order in which you raised them to Stockport NHS Foundation Trust: 1. The doctor who discharged the patient from the hospital as being “medically fit for discharge” did so without ever seeing the patient. In his statement to the inquest he says “I am afraid | have never seen Mr Rogers...he was seen by two consultant colleagues...) was asked if he could go home by one of the nurses...was shown the notes...asked the nurse to follow the team’s pre-arranged plan i.e. to discharge the patient. It is noted that Mr Rogers went home by bus”. The fact that a doctor not only discharges a patient in this way but also has no compunction in saying that he has done so in a statement to a Coroner, suggests a fundamental lack of understanding as to the importance of ensuring that all factors are in place for discharge, including medical and social issues It is normal practice for all patients to have a written plan by a consultant in relation to their discharge. In this instance, a plan was put in place by an Acute Medicine Consultant in conjunction with a previous review by a Consultant Diabetologist and the Diabetes Nurse Specialist. It appears that this plan was adhered to in relation to the patient’s ketones level which, when measured, was negative and therefore the plan for discharge was followed. 2. During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin. This was then given later but this meant that his regime had been altered and he would have to re-set the regime at home. This dose was missed due to the ongoing issue of paper charts being used in the Emergency Department (ED) and the fact that the ED electronic system (AdvantisED) cannot interface with the electronic prescribing system (ePMA). The Diabetes Specialist Nurse prescribed Levemir on a paper chart whilst in ED. This chart was then mistakenly filed at the back of the patient's paper record on the ward and was therefore missed by nursing staff. Arisk assessment is already in place within the Trust regarding this issue and staff are reminded on all wards to check for any paper charts. The Trust is moving towards a Trust wide electronic patient record (EPR) which should resolve this issue, but in the meantime, | can confirm that there isa specialist “Task& Finish Group” in-place to further-review this issue and develop.an effective interim solution. This group reports to the Trust's Risk Management Committee and through this to the Quality Governance Committee and the Quality Assurance Committee, which reports directly to the Board of Directors. |_am able to confirm that the potential serious incident investigation has been concluded. The outcome of the investigation and the agreement of the validation team was that there were no serious acts of omission or commission regarding the patient's care and as such this has not been deemed a Serious Incident. There are of course lessons that can be Jearnt and therefore there is an action plan associated with the report which we will share with you when it is finalised. | hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if you have any further questions regarding this matter. Wi Youry Sificerely
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