Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0033, written 5 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2016 |
|---|---|
| Reference | 2016-0033 |
| Deceased | Douglas Kay |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of the Doncaster and Bassetlaw Hospitals NHS Foundation Trust (the Trust) 1 | CORONER | am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 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 1* December 2014, | commenced an investigation into the death of Douglas Kay, aged 90 years. The investigation concluded at the end of the inquest on 14 " August 2015. The conclusion of the inquest was one of Natural Causes 4 | CIRCUMSTANCES OF THE DEATH Mr Kay was an elderly man, but was reasonably fit for his age. He presented to Bassetlaw Hospital with bleeding from a duodenal ulcer on 16" November 2014. He was admitted, monitored and given medication to try and heal the ulcer. On the evening of the 22" November, Mr Kay became suddenly unwell with clear evidence of active bleeding from the ulcer, with a blood stained vomit and black stools. This was a catastrophic bleed and despite attempts to resuscitate him, he died approximately 7 hours later. Throughout the period of his deterioration there was significant confusion about the arrangements for a possible transfer to Doncaster Hospital for further treatment. The Trust completed an Investigation report, produced an action plan, and submitted further reports during the Inquest. All these documents went some way to addressing concerns raised in evidence, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed. 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. — e There remain significant confusion, and uncertainty about how, and when, to transfer a patient with gastrointestinal bleeding, with no clear agreed policy or procedure available within the Trust e There are new arrangements for the provision of a gastrointestinal bleeding service at Doncaster Hospital, but key Senior staff at Bassetlaw Hospital are not aware of how it operates, particularly out of hours. 6 | 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 the 11" April 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 copy of my report to the Chief Coroner and to the following Interested Persons: a: and next of kin lam 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. 5" February 2016 Dr E A Didcock Ce $y)
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.
Doncaster and Bassetlaw Hospitals NHS) NHS Foundation Trust we Care r in | Medical Director’s Office cic Director (3630) Mr RJ Cuschieri, Deputy Medical Director — Clinical Standards (4714) Dr R Harris, Deputy Medical Director — Professional Standards (3376 or 75 2275) Karen Humphries, Clinical & Professional Standards Co-ordinator (3637) Jacqueline Ford, Executive PA to Medical Director (3183) Our Ref RJC/jj 1 April 2016 Dr E Didcock HM Assistant Coroner for Nottinghamshire The Council House Old Market Square Nottingham NG1 2DT Dear Dr Didcock | write with respect to the concluded inquest on Douglas Kay and the Regulation 28 report dated 5 February 2016 where concerns have been highlighted with respect to arrangements for the management and transfer of patients with gastrointestinal bleeding (GI Bleed) at Bassetlaw Hospital. The report was addressed to the Chief Executive of the Doncaster & Bassetlaw Hospitals NHS Foundation Trust and | have been tasked with addressing the issues identified in your report. | have been assisted in the course of this by BE onsuitant Gastroenterologist and clinical lead for GI bleeding with contributions from Dr Gurgit Singh, Consultant Gastroenterologist, Bassetlaw Hospital and Dr Vinesh Vincent, Consultant Anaesthetist/Intensivist at the same hospital. | attach two documents with respect to the concerns highlighted. Document 1 is the standard GI bleed pathway for any patient presenting with a gastro-intestinal bleed to the Doncaster & Bassetlaw Hospitals NHS Foundation Trust. The 2"? document and the one which is particularly relevant in this case is the Upper GI Bleed Transfer Policy at Bassetlaw Hospital for those patients who require to be referred to Doncaster for further management of their upper GI bleeding. This policy has been developed after consultation between the anaesthetic and the medical teams. All staff will be made aware of this specific transfer policy at Bassetlaw through the Clinical Site Manager and Matron at Bassetlaw. The policy will also be ratified at the next meeting of the Patient Safety Review Group and this will ensure wider dissemination throughout the Trust. | trust that this will provide the assurance you require that appropriate action has been taken following the death of Douglas Kay. The implementation will continue to be monitored by the Emergency Care Group Clinical Governance Team through the Datix incident system. May | take this opportunity to invite you to revert back to me should you feel it necessary to do so. Yours sin¢erely A —_ Mr R. J. Cuschieri MD. aA M.Ed FRCS Deputy Medical Director - Clinical Standards Cc Mr M Pinkerton, Chief Executive, DBHFT Mr S Singh, Medical Director, DBHFT Deputy Director of Quality & Gvernance | Consultant Gastroenterologist/Gl Clinical Lead HE Assistant Care Group Director, Surgery Care Group Director, Emergency Medicine Consultant Gastroenterologist, Bassetlaw Consultant Gastroenterologist, Bassetlaw linical Lead Accident & Emergency Services SENS Consultant Anaesthetics/Intensivist HE Viatron Emergency Services, Doncaster P| Matron, Emergency Services, Basetlaw
See every Prevention of Future Deaths report matching Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.