Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0147, written 19 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Apr 2016 |
|---|---|
| Reference | 2016-0147 |
| Deceased | Leslie Carswell |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sandwell and West Birmingham Hospitals 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
THIS REPORT IS BEING SENT TO:
1. Sandwell and West Birmingham NHS Trust
2. University Hospital Birmingham NHS foundation Trust
4
beriplex more quickly which contributed to his death.
1 CORONER
lam Louise Hunt Senior Coroner for Birmingham and Solihull
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 10/12/2015 | commenced an investigation into the death of Leslie William Carswell. The investigation
concluded at the end of the inquest 19th April 2016. The conclusion of the inquest was that the deceased
died from a brain bleed following a fall. There was a delay in reviewing the CT scan and administering
CIRCUMSTANCES OF THE DEATH
The deceased was admitted to D7 at City Hospital on 18/11/15 following a transcatheter aortic valve
implementation at New Cross Hospital. He was transferred to ward D47 on 22/11/15 for rehabilitation.
He was assessed to be at high risk of falls. He was seen regularly by physiotherapists and assessed to be
improving. He had capacity and was informed to use his call bell when mobilising. At 19.25 on 29/11/15
the deceased was found face down on the floor having been to use the toilet. He was taken to Sandwell
hospital emergency department, as per protocol, where a CT scan at 00.50 confirmed bilateral sub-acute
on chronic subdural haematoma. A decision was made at 02.30 to give Beriplex to reverse the effects of
warfarin however the deceased suffered a further serious bleed at 05.05 before this could be given. He
died on the intensive care unit at 12.30 on 30/11/15.
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) There were technical difficulties transmitting the CT scans taken at 00.50 to the Queen Elizabeth
Hospital in Birmingham for review which is the protocol for the west midlands. This caused a delay in
deciding a treatment plan. | heard evidence at the inquest that these concerns are ongoing and no
resolution has been found. There is a concern that patients with urgent conditions could have lifesaving
treatment delayed due to technical difficulties between the two trusts.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and { believe you Sandwell and West
Birmingham Hospitals NHS trust 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
15 June 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.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the family. | have also sent it to NHS England
who may find it useful or of interest.
*
1 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 19/04/2016
Signature
Louise Hunt Senfor Coroner Birmingham and Solihull
|
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.
Sandwell and West Birmingham Hospitals
NHS Trust
City Hospital,
Dudley Road, Birmingham, B18 7QH
Chief Executive's Office:
0121 507 4847
13 June 2016
Your ref: as
PRIVATE & CONFIDENTIAL
Mrs Louise Hunt
H.M. Coroner
Birmingham and Solihull Areas
Coroner’s Court
50 Newton Street
Birmingham
B4 6NE ty than
Dear Mrs Hunt
Re: Report to Prevent Future Deaths — Leslie William Carswell
{am in receipt of your Report to Prevent Future Deaths in respect of Leslie William Carswell dated 20
April 2016, and in line with your requirements am responding within the 56 days allowed.
As a Trust we have taken action to address the matter of concern you have highlighted in your letter,
namely technical difficulties transmitting CT scans to the Queen Elizabeth Hospital as per the protocol
for the West Midlands.
| have outlined below the actions that we have already initiated within the Trust:
1. Procedure — the Image Exchange Portal (IEP) Standard Operating Procedure was updated to
clarify how images are transmitted, including contingencies for out of hours and / or if there is
a technical fault. The updated procedure includes changes to documentation requirements for
audit trail purposes. This updated documentation procedure went live on 3 June 2016, System
based audit trails are being looked into.
2. System configuration — all three SWBH CT scanners can send images directly to UHB. One of
the CT scanners at Sandwell Hospital can send to Birmingham Children’s Hospital. Work to
ensure all SWBH CT scanners are configured to send images to Heartlands and Birmingham
Children’s Hospital is in progress. Configuration to the Children’s Hospital is scheduled for
completion by mid-June. A request for configuration work was submitted to IT colleagues at
Heartlands in May 2016 and once approved it will take approximately two weeks to allow for
firewall configuration and testing. These configurations will be a fixed point in our Managed
Equipment Service specification.
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3. Training - all radiographers (seventy members of staff who work various shift patterns) are
being trained in IEP and Image Link, with a documented process for competency sign-off.
Training commenced in June 2016 with a planned completion by the end of September 2016.
4. Audit / monitoring — A weekly data report from the CRIS system has been set up to monitor
image transfers performed out of hours, which is reviewed by the Group’s management team.
A second data report from the IEP system gives an independent result for cross-checking
against the CRIS system report, These monitoring reports will identify the member of staff who
transferred the images, the destination, the time, the modality type and a summary of the
patient details.
| hope that | have offered assurance that we have taken the points you raised seriously and have
implemented actions to prevent re-occurrence.
However, if you have any further questions, please do not hesitate to contact {EEE Assistant
Director of Governance on
Yours sincerely
Wy
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Toby Lewis
Chief Executive
Shey,
sYYS
eA A University of Birmingham Teaching Hospital
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