Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0162, written 22 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 | 22 Apr 2016 |
|---|---|
| Reference | 2016-0162 |
| Deceased | Marina Fagan |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: (1) The Right Honourable Jeremy Hunt, Secretary of State, Department of Health, Richmond House, 79 Whitehall, London. CORONER lam R Brittain, Assistant Coroner for inner North London 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. INVESTIGATION and INQUEST Marina Fagan died on 6 October 2015, aged 50 years, from a rare but severe neurological disorder, Posterior Reversible Encephalopathy Syndrome/Reversible Cerebral Vasoconstriction Syndrome (hereafter PRES). An inquest into her death was heard on 22 April 2016, at which | recorded a conclusion of natural causes. CIRCUMSTANCES OF THE DEATH Ms Fagan was admitted to hospital on 17 September 2015, suffering with a headache. She was discharged on 19 September after investigations ruled out a subarachnoid haemorthage. On that day she reattended the Accident and Emergency department of the same hospital suffering from headache and was discharged after a neurological examination showed no abnormalities. A recommendation was made to her GP to refer her to neurology outpatients. This referral was undertaken on 24 September but Ms Fagan reattended hospital on 25 September with further headache symptoms. She became confused on 26 September but it was not until 29 September that a clinical review demonstrated the presence of visual loss and eye movement palsy. An MRI was undertaken on 30 September, which demonsrated PRES; transfer to a tertiary care hospital occurred. Despite supportive treatment Ms Fagan died from PRES on 6 October 2015. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concem. 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) [heard evidence from the neurologist who treated Ms Fagan that, had the headache been persisting on 19 September (which was unclear from the evidence), then he would have expected to be involved in her care, He went on to state that an MRI would have been requested on that day. He also set out his expectation that neurology input should have been initiated after Ms Fagan developed confusion on 26 September, at which point an MRI would also have been requested. However, it was clear from his evidence that, even had PRES been diagnosed earlier, it would not have been treatable, given the severity of the condition. This witness set out his concer that, nationwide, there are insuffient neurologists to provide necessary specialist care. He noted that in the out of hours setting, although there were neurologists available the nearby tertiary care hospital, none were on-call in the hospital to which Ms Fagan was initially admitted. Ms Fagan's general practitioner set out that the current waiting time to see a neurologist in the outpatient setting, is 72 days. Given the issues regarding availability of specialist neurological care, | am concerned that future deaths will occur in similar circumstances. ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and | believe that the addressee, has 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 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner, Ms Fagan's family and Barts Heaith NHS Trust. | 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. Assistant Coroner R Brittain mA Ll
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.
in From Ben Gummer MP ‘ Parliamentary Under Secretary of State for Care Quality Department Richmond House of Health 79 wrierll POC 1032028 SW1A 2NS Tel: 020 7210 4850 DrI R. Brittain Assistant Coroner St Pancras Coroner’s Court Camley Street London ~\ N1C4PP [(¢ June 2016 | ( (i be Thank you for your letter of 22 April 2016, following the inquest into the death of Marina Fagan. I was sorry to hear of Ms Fagan’s death and wish to extend my sincere condolences to her family. Posterior Reversible Encephalopathy Syndrome (PRES) is a rare disease, which I understand was first described only in 1996, and differential diagnosis can be difficult. This means that many other common conditions can present with very similar symptoms to PRES. I understand that you heard evidence that in Ms Fagan’s case her condition was so severe that, even had a diagnosis been made earlier, the outcome was unlikely to have been different. I note your concerns about the availability of neurologists locally and nationally. You had particular concerns about the time taken to see a neurologist in an outpatient setting and the availability of on-call neurologists in hospitals. It is the responsibility of providers to ensure that they have appropriate staffing levels to meet the needs of their patients. The availability of neurologists locally is therefore for Barts Health NHS Trust to address. On a national basis, Health Education England (HEE) plans the future workforce. HEE has consistently invested in the commissioning of training places in neurology and intends to commission 219 training places in 2016/17, a small rise from 217 in both 2014/15 and 2015/16. Turning to waiting times, the NHS Referral to Treatment (RTT) waiting time standard is that 92% of patients should wait no more than 18 weeks before starting consultant led treatment for non-urgent conditions. This would be the case for outpatient appointments, which would by definition be non-urgent. Where this is not possible, the NHS should take all reasonable steps to offer a range of suitable alternative providers able to see or treat the patient more quickly than the original provider, if this is what the patient wants and it is clinically appropriate. Commissioners are not obliged to take all reasonable steps to find an alternative provider if the patient does not ask for this. Some patients will wait longer than 18 weeks by choice, for personal or social reasons, or because this is clinically appropriate. Data is collected and published by NHS England to monitor performance against the standard, across all specialties in England, and for 18 high volume specialties including neurology. At the end of February 2016, 92.1% of patients on an incomplete pathway, and 92.3% of patients on an incomplete neurology pathway, were waiting less than 18 weeks. Ona national level therefore, the waiting times for neurology meet the operational waiting time standards. Further figures show the average (median) waiting times to start consultant-led treatment in February 2016 were: e in an admitted patient setting: 10.3 weeks for all specialties and 3.1 weeks for neurology e inn outpatient setting: 5.9 weeks for all specialties and 6.2 weeks for neurology. Clinical priority is the main determinant of when patients should be treated and clinicians need to make informed treatment decisions so that patients do not experience undue delay at any stage of their referral, diagnosis or treatment. Patients should be treated according to clinical priority and then normally in the chronological order of when they were added to the waiting list. I hope that this reply is halpful and I am grateful to you for bringing the circumstances of Ms Fagan’s death to myattention, BEN GUMMER
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