Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0034, 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 | 2016-0034 |
| Deceased | David Mostari |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire and Luton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Bedford Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Thomas R Osborne
Senior Coroner for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr Stephen Conroy
Chief Executive
Bedford Hospital NHS Trust
Kempston Road
Bedford
MK42 9DJ
1
CORONER
I am Thomas R Osborne, Senior Coroner for Bedfordshire and Luton
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 14 August 2015 I commenced an Investigation into the death of David MOSTARI, aged
70 years. The Investigation concluded at the end of the Inquest on 13 January 2016. The
Conclusion of the Inquest was a ‘Narrative Conclusion’ that: “…The deceased was admitted
to Bedford Hospital on 8 August 2015 at 11:03 hours. He was seriously unwell and there was
a failure to recognise the serious nature of his condition and a failure to take the necessary
steps to treat him appropriately. This resulted in a lost opportunity to intervene earlier and he
died on 10 August 2015 from peritonitis following a perforated bowel”.
4
CIRCUMSTANCES of the DEATH
The Deceased was admitted to Bedford Hospital South Wing at 11.03 hours on 8 August 2015
with a history of suggested flare up of his ulcerative colitis. He was managed on a Ward until
he deteriorated in the early hours of 10 August 2015. He was then taken to the Critical Care
Complex and subsequently into theatre where a laparotomy was performed. A perforated
colon with widespread faecal contamination was found, and a partial colectomy
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
performed. On return from theatre he remained moribund but further resuscitation allowed
commencement of haemofiltration. Unfortunately he continued to deteriorate and later that
evening it was apparent that treatment was futile and hence, with the agreement of the family,
withdrawn.
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. Mr. Mostari was admitted to the Hospital on a Saturday and despite the need for an
urgent x-ray and ultra sound scan the tests were not in fact carried out until the
Monday. There therefore does not appear to be any robust system in place for ensuring
that urgent tests and imaging are carried out without delay, particularly when a patient
is admitted at the week-end. The deceased needed the tests and follow up treatment as
a matter of urgency.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you as the Chief
Executive have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this Report,
namely by 2nd April 2016. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Person(s)
The family via son –
I have also sent it to:
The Care Quality Commission (via e-mail)
who may find it useful or of interest
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
9
Dated 5th February 2016
………………………………….
TOM OSBORNE
Senior Coroner
Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
gy Kempston Road Bedford MK42 9DJ Your ref:38671-2015 Tel: 01234 355122 Trust Ref SC/ALD Fax: 01234 218106 1 April 2016 Mr Tom Osborne HM Senior Coroner for Bedfordshire and Luton Coroner's Office The Court House Woburn Street Ampthill MK45 2HX Dear Mr Osborne Regulation 28 Report Following Inquest into the death of David Mostari Thank you for the report dated 5 February, sent to the Trust under cover of a letter from your Senior Officer dated the same day. The Trust was obviously very concerned that you considered there is a risk of future deaths as there did not appear to you any robust system in place for ensuring that urgent tests and imaging are carried out without delay, particularly at the week end. . The Trust has therefore developed and is in the process of implementing the attached position statement/ action plan in order to ensure that there is a robust system in place. | hope that this will give you sufficient assurance that the appropriate steps have been or will be taken to reduce the potential risk of future deaths. A copy of this letter and the attachment is being sent to both Mr Andrew Mostari, as an interested party and the CQC. A copy of the covering letter to Mr Mostari is attached. Yours sincerely ae Ay a ! Stephen Conroy / Chief Executive ABoy, aa & v osess = es POS, o% es ea 21543 INVESTOR IN PEOPLE Bedford Hospital NHS Trust South Wing Kempston Road Bedford MK42 9DJ Tel: 01234 355122 Trust Ref SC/AL Fax: 01234 218106 — 1 April 2016 Mr Andrew Mostari 16 Partridge Piece SANDY Beds $G19 2UP Dear Mr Mostari Regulation 28 Report Following Inquest into the death of David Mostari May | on behalf of the Trust extend my unreserved apologies for the failures in the care offered by the hospital during your father’s final illness, as identified in the Trust’s serious incident investigation report. Please accept my sincerest condolences. The Trust was obviously very concerned that at the Inquest, the Senior Coroner considered there was a risk of future deaths as there did not appear to him to be any robust system in place for ensuring that urgent tests and imaging are carried out without delay, particularly at the week end. The Trust has therefore developed and is in the process of implementing the attached position statement/ action plan in order to ensure that there is a robust system in place. | hope that this will give you sufficient assurance that the appropriate steps have been or will be taken to reduce the potential risk of what happened to your father happening again. A copy has been sent to the Coroner. If you have any queries, or would like to discuss further what happened to your father, do please contact me and | will do my best to ensure that you get .the answers you want. Spo Yours sincerely Stephen Conroy Chief Executive yo Ay SA fy } Z. gh _ t . ew www.bedfordnospital. nns.uk As4e INVESTOR IN PEOPLE Bedford Hospital NHS | Hospital at Night NHS Trust Out of hou rs handover (please complete in block capitals) Handover details Handed over by Handed over to Day(s) covered by this handover (please circle) Mon Tue Weds Thu _ Fri Sat Sun Patient Responsible . . . Aims and limitations of treatment surname, forename consultant, Diagnosis/ Pro blem list Outstanding issues (eg resus/ITU/ventilation/ inotropes/active/ date of birth. patient current differential diagnosis Reason for handover (tasks to be done) palliative/ d NHS hospital no location (include any risks or warnings) : surgery — yes/no) Weekend discharge yes/no Weekend discharge yes/no Weekend discharge yes/no Weekend discharge yes/no Weekend discharge yes/no Bedford Hospital NHS) NHS Trust Position Statement/ Action plan in response to Coroner’s conclusion and section 28 report following the Inquest into the death of David Mostari Concerns identified; There does not appear to be any robust system in place for ensuring that urgent tests and imaging are carried out, without delay, particularly when the patient is admitted at the week-end Current position/ proposed action Imaging Plain-xray 1. 24/7 service available. Radiographer on premises on call CT scanning 1. Routine CT lists run Saturday and Sunday 10am - 1 pm for routine and emergency cases 2. Access to CT scanning 24/7 on call, most indications are based on protocols e.g. head injury 3. Other requests can be made via on-call consultant discussion with an on call radiologist for imaging of any patient. Ultrasound imaging 1. Available by on-call consultant discussion with an on call radiologist for imaging of any patient. 2. Available 7 days a week and 365 days a year mR Imaging . Available 7 days a week but currently not available out of hours as an emergency service. Patients requiring MRI for specific condition e.g. spinal condition transferred to specialist centre. 2. Radiologist on-call available however out of hours as well as in hours to discuss any cases and discuss alternative imaging modalities if appropriate Fluoroscopy, Special procedures (e.g. Barium enema, nephrostomy), Requests can be made via on-call consultant discussion with an on call radiologist for imaging of any patient. General Electronic reporting and availability of images has been in place for several years On-line electronic requesting of radiological examinations to be introduced and rolled out in starting in April 2016. Training provided Bedford Hospital INHS NHS Trust — Full details of services available and requesting arrangements now publicised on trust intranet. Pathology Laboratory open and staffed 24/7 for testing of specimens. Pharmacy Opening Hours extended during 2015 to Monday- Friday 8.30-6.30, Saturdays 9-4, Sundays 11-4. Endoscopy Following extensive refurbishment and extension of the department in 2016/17, this services is now able to offer a full 8am-6pm service 7 days a week for Gastroscopy, Trans Nasal Endoscopy, Colonoscopy, Flexible Sigmoidoscopy, Cystoscopy, Bronchoscopy, ERCP and Breath Tests. Medical Handover Under the Hospital at Night development, an electronic handover sheet has been developed, to highlight outstanding tests/ results to doctors on change of shift to ensure that investigations are pursued/ acted on - sample attached This process was been audited in March 2016 as part of the SI action plan. Details of these services and how to access them have since February 2016 been included in the new doctor locum packs available on the Trust’s intranet. SC/ALD v2 31/3/16
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