Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0258, written 14 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jul 2016 |
|---|---|
| Reference | 2016-0258 |
| Deceased | Patrick Curran |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mrs Diane Whittingham, Chief Executive, University Hospital South Manchester NHS Foundation Trust Southmoor Road Wythenshawe Manchester M23 9LT 1 | CORONER Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South. 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 On 26" February 2016 an investigation was commenced into the death of Patrick Curran who died at Trafford General Hospital on 22™ February 2016. The investigation concluded with an Inquest held on 13" duly 2016. :Medical cause of death la Pneumonia lb Asbestosis, Chronic Obstructive Pulmonary Disease, and Adenocarcinoma of the lung (treated surgically) Ic Smoking and asbestos exposure | Coronary artery atheroma Conclusion: Industrial Disease CIRCUMSTANCES OF THE DEATH In December 2015 Mr Curran was diagnosed with Stage 1B lung cancer (T2a NO MO) as determined by PET scan carried out at the Manchester Royal Infirmary. Mr Curran was referred —_ Consultant in Thoracic Surgery. On 5" January 2016 Mr Curran underwent resection of the upper right lobe, and mediastinal lymph nodes. Following surgery and histology the tumour was re-staged as a Stage 3A (T3 N2 MO) poorly differentiated adenocarcinoma. Mr Curran was discharged on the 4" post-operative day, 9" January 2016. He was discharged with a chest drain in situ. With regard to the chest drain Mr Curran was reviewed in a ‘nurse-led’ clinic on 18" January, 25" January and 29" January. At the last appointment the chest drain was removed. At none of these appointments was Mr Curran seen by a doctor. Mr Curran attended for his first post-discharge review on 12" February. He was seen by a Senior Specialist Nurse in Thoracic Surgery. It was noted that Mr Curran, - looked a bit frait - was struggling to recover post-operatively - was low in mood - had poor appetite and had lost weight, and that his family were encouraging him to have Fortisips between meals in an attempt to regain weight In his statement [I refers to the fact it was obvious, at that clinic, that Mr Curran would not be able to tolerate adjuvant chemotherapy. That could only be based on the Sister's assessment. accepted that such a presentation would not be the norm for a 4-weeks post discharge review. A chest xray was taken. Fs stated in evidence that he reviewed this xray. In his evidence he said there were no obvious suggestions of an ongoing chest infection. | have not seen the radiologist’s report of that xray. | do not therefore know whether that statement is correct either in so far as it related to obvious signs and in addition whether more subtle changes were present. Although| was asked to review the xray by the Sister he was not asked to see Mr Curran. accepted in evidence that he ought to have been asked to see Mr Curran, and a fortiori he would have done. Mr Curran was discharged by the Sister back to NS MMedvised that it would likely be 3-4 weeks before Mr Curran was seen. was not immediately aware that Mr Curran had been discharged and that he had not seen him post-op. An attempt was made to contact Mr Curran on 22™ February. Mr Curran was admitted to Trafford General Hospital on 17" February. He was very unwell. The impression was of a pneumonia that had “been developing for a period of weeks’. It was treated, given the history of recent admission for surgery, as a hospital acquired pneumonia and IV Tazocin administered. Treatment was unfortunately not successful and Mr Curran passed away in the early hours of 2a" February. CORONER'S CONCERNS It is highly likely that Mr Curran had a pneumonia on 12” February, hence his presentation as described by the Specialist Sister. It is possible that the pneumonia was present at the chest drain reviews. It causes me great concern that a patient who must have been presenting as unwell and not as expected at a 4 weeks post-operative was not only not seen by a doctor, but was discharged without the Consultant in charge’s knowledge. | also have concerns about the fact that over 3 appointments at a ‘nurse-led’ clinic despite there being issues with the chest drain Mr Curran was not once reviewed by a doctor. arena told me that he spoke with the Specialist Sister involved but | am not satistied that this provides me with adequate assurance that, a) first post-operative reviews and discharges of patients without a doctor seeing that patient is not a common and accepted practice, in the main because in many of the answers given to me on this element of the care provided to Mr Cura was keen to enlighten me as to how experienced this particular Specialist Sister was. b) and in the circumstances this will not happen again. | had no evidence as to whether or not had one Mr Curran the outcome would have been different. It seems to me that there was at least the possibility that the outcome would have been different. 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. That Wythenshawe Hospital have adopted or condoned a practice whereby first Post-operative reviews are conducted by nursing staff (of whatever specialist level of training) without any or any adequate medical overview. 2. That Wythenshawe Hospital have adopted or condoned a practice whereby patients can be, and are, discharged from care ai first post-operative review, or indeed any review, by nursing staff (of whatever specialist level of training) without any or any adequate medical overview. ACTION SHOULD BE TAKEN In my opinion action should be taken by Wythenshawe Hospital to investigate the circumstances of Mr Curran’s discharge from care on 12" February at his first post- operative review without being seen by his operating surgeon, or any other doctor, when he was clearly not recovering well and in line with expectations. Having carried out such an investigation to then set in place a system that would avoid a recurrence of the same, whether or not the patient presents as unwell. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8” September 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner. | have sent a copy of my report cf | 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. 14.07.2016 Mr Andrew Bridgman Assistant 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.
University Hospital of South Manchester INHS| NHS Foundation Trust Medical Director's office Wythenshawe Hospital Trust HQ R EC E IVE D " Southmoor Road Tel: 0161 297 2027 Wythenshawe Fax: 0161 291 2037 ~7 SEP 2016 Manchester M23 SLT Tet: 0161 998 7070 5 September 2016 Mr Andrew Bridgman Assistant Coroner Manchester South 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Bridgman, Re: PFD Patients Name: Patrick Curran D.0.B: 06.12.1933 D.O.D: 22.02.2016 RM No: RM267048 | am responding to the Regulation 28 — Prevention of Future Deaths Report Issued to University Hospitals of South Manchester (UHSM) on 14 July 2016. 1. Concern: That Wythenshawe Hospital have adopted or condoned a practice whereby first post-operative reviews are conducted by nursing staff (of whatever specialist level of training) without any or any adequate medical overview. Thank you for making the Trust aware of your concerns. In line with a national move towards nurse-led clinics the expertise and training of our nursing staff renders them very capable of conducting post-operative clinics in the cardiothoracic unit. Thoracic surgery patients are seen in the outpatient clinic for their follow ups by any member of the team and this could be the Consultant, Registrar, SHO or a specialist nurse who has many years of thoracic surgery experience. All clinics are supported by Consultant cover as required. If there are concerns with a patient they are always discussed with the Consultant or if there are any concerns with an x-ray, Radiology are asked to report these. Notwithstanding this, we would like to reassure you that there was medical oversight at these clinics. When Mr Curran was seen at clinic in February 2016, the clinic would be nurse-led with the consultant surgeon available by telephone. We have strengthened this and now our post-operative clinics are led by nurses but with a consultant present in the same clinic. 2. Concern: That Wythenshawe Hospital have adopted or condoned a practice whereby patients can be, and are, discharged from care at first post-operative review, or sABOy, Ae fs We Chairman - Barry Clare U S M a ae on eee Mb, oy INVESTORS rs 4,2 IN PEOPLE ROSiz, indeed any review, by nursing staff (of whatever specialist level of training) without any or any adequate medical overview. Thank you for making the Trust aware of your concerns. As set out above, the system has been strengthened and a consultant is present at the first post-operative review clinic. Mr Curran's x-ray taken on 12 February 2016 did not reveal! a chest infection or pneumonia. A plan was made, on the basis that Mr Curran’s histology was not currently available, for him to receive his histology at a separate time by way of follow up from EEE.“ The decision regarding chemotherapy was not made until the histology was available. It was therefore, in our view, entirely appropriate, based on his presentation on 12 February 2016 to discharge him albeit without his histology results which were to be given at a later appointment. EE dic not feel the need to review Mr Curran but had he been asked to review Mr Curran, it is his view that based on his x-ray and the description of Mr Curran’s presentation he would not have admitted him. The x-ray from the 12 February 2016 was compatible with post-operative findings. lf you require any further information, please do not hesitate to contact me. Yours sincerely, Medical Director, UHSM
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