Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0018, 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 | 2016-0018 |
| Deceased | Derek Hare |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside Hospital 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: Chief Executive, Tameside Hospital NHS Foundation Trust 7 | CORONER | am 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 19" August 2015 | commenced an investigation into the death of Derek Edward Hare dob 15" August 1937. The investigation concluded on the 13” January 2016 and the conclusion was one of Misadventure. The medical cause of death was 1a Multi organ failure 1b Chest and abdominal sepsis 1c Colonic Anastomotic Failure treated by surgery on 19.6.15: Embolization on 17.4.15 after Colectomy for diverticulitis on 14.1.15 11 Ischaemic Heart Disease. wal 4 | CIRCUMSTANCES OF THE DEATH Mr Hare was subject to severe abdominal pains and he was admitted to the hospital in January 2015 and was operated on fora colectomy. Thereafter he asked a numerous occasions to see the surgeons again as he was still in pain and was passing blood per rectum, but was refused/denied the chance to see the doctor. Eventually he was looked at and it was determined that one of his major blood vessels needed embolization. This embolization was done at Wythenshawe Hospital and on his return to Tameside he underwent a colonoscopy to examine the bowel. The embolization had compromised the blood supply to that part of the bowel where the anastomosis had been formed, and when the bowel was inflated for the colonoscopy, it caused the anastomosis to fail leading to a loss of bowel content and the development of sepsis in the abdomen and the chest. 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 would appear that throughout his various admissions to the hospital, two completely separate sets of “notes” were open and being used. Thus when the doctor tried to refer to the notes in court he could not do so and had to seek a short adjournment to find the relevant entry. If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient. 2. The deceased incessantly asked for appointments at the hospital because he knew that his abdomen was “not right”, yet he was constantly refused/denied such an appointment. This meant that it is possible that the problem which he had was diagnosed much later than might have been the case, and the outcome might have been different. 3. On the 5” May 2015 he was admitted via emergency ambulance to TGH with abdominal pains. On the 6 May it was determined that he did not need an emergency colonoscopy and the “urgency was not there”. He was sent home. He attended on the 19°" June and had to undergo a laparotomy when the problem of the broken anastomosis was discovered and he died on the twelfth August. It was agreed by one of the consultant surgeons giving evidence to me that it would have benefitted his care to have kept him in hospital on the 6" May. 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 17" 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 c ort to the Chief Coroner and to the following Interested Person namel (brother of the deceased). | have also sent it to the ca@c . who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. er may publish either or both in a complete or redacted or summary end a copy of this report to any person who he believes may find it useful ou may make representations to me, the coroner, at the time of your about the release or the publication of your response by the Chief Coroner. The Chief form. He or of intey 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.
Tameside Hospital RECEIVED NHS Foundation Trust 3.1 MAR 2016 eR. Quality & Governance Unit weee eer Tameside General Hospital Fountain Street Ashton-Under-Lyne Tameside OL6 SRW Telephone: 0161 922 4466 Fax: 0161 922 6190 Date: 23 March 2016 Your Ref: JSP/ER/01978-2015 Our Ref AD/KJ/01978-2 Mr John Pollard Senior Coroner for Manchester South The Coroner's Court 1 Mount Tabor Stockport SK1 3AG Dear Mr Pollard, Re: Regulation 28: Report to Prevent Future Deaths following Inquest into the death of Derek Edward Hare (Deceased) | write further to your letter dated 16" March 2016 in relation to the Trust’s response to your Regulation 28 Report issued following the Inquest, touching upon the death of Derek Edward Hare, on 13" January 2016. | am very sorry that you had cause to contact me again and that you found the response given to point 1 of your Regulation 28 Report unsatisfactory. ! hope to be able to address your concerns as set out in section 5 of your report, to your satisfaction in this letter. With reference to why the response to your Regulation 28 Report typed on the 8" February took a month between being typed and being sent to your office, Iam very sorry for the confusion this caused and would like to assure you that this was a clerical error, and the letter should have been dated 28" February not the 8"" February. In response to point 1, you stated: 1. It would appear that throughout his various admissions to the hospital, two completely separate sets of “notes” were open and being used. Thus when the doctor tried to refer to the notes in court, he could not do so and had to seek a short adjournment to find the relevant entry. If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient. It was not a question of large case notes which run into two volumes, this was a situation where both sets of notes were apparently open at the same time and doctors were therefore putting new notes into one or the other but not properly into one single document. In respect of your concerns regarding the case notes | recognise that staff entries into the records should be in one set of records which should be the current ones in use during the patient's admission. This is the Trust's standard and expectation and has been reiterated to-the- Consultant-Clinical_Leads, Lead_ Clinicians and. Senior Nurses_in_the—Clinical Divisions for dissemination to all staff and for discussion at their Clinical Governance and team meetings. As you have highlighted where it is necessary to provide two sets of notes for reference to the previous history and. continuity of care there is a risk that medical staff may enter their notes in the older set of notes. This reiteration and reinforcement of the record keeping policy will minimise this. i have sought further clarity as you suggested on the problems encountered at Mr Hare's Inquest in this regard and have liaised with Mr Siddiqui. As previously stated two large sets of case notes pertaining to the patient were made available for Inquest. The Consultant Mr Siddiqui maintains that he was asked to clarify a date in response to a question raised by Mr Hare's relative. Mr Siddqui informs me that he found it necessary to look at the notes which were in a different volume of the case notes and as such had to manage both volumes at the Inquest. | acknowledge that this was not ideal and further enquiries have informed me that it appears that one set of case notes has records filed up to the 27/05/15. This volume held some of the notes Mr Siddiqui had to access (these related to the surgical care) in response to your questions. The other volume has records up to the patient’s death on the 12/08/15. This contained medicine specialty notes and notes where the surgeons had been asked to review Mr Hare) which were also pertinent to the questions asked. | am very sorry that this resulted in you having to adjourn the Inquest to give time for Mr Siddiqui to find the entry and for any inconvenience this caused you in respect of your HM Coronial Hearing. | also recognise that this gave rise to your concerns in relation to the Trust's ability to provide high quality care for the patient. | hope you will find my actions in relation to the concerns you have raised satisfactory. | would like to assure you that | have taken your concerns serlously and | hope that | have addressed your concerns and reassured you of all that the Trust has already undertaken and is currently undertaking, in order to prevent the recurrence of a similar set of circumstances in the future. Should you have any further questions arising from the contents of this letter, please do not hesitate to contact me. Yours sincerely (KO) Kalen James Chief Executive
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