Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0271, written 27 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 | 27 Jul 2016 |
|---|---|
| Reference | 2016-0271 |
| Deceased | Cerith Pugh |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire and Pembrokeshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Chief Executive of Hywel Dda University Health Board Withybush General Hospital Fishguard Road Haverfordwest SA61 2PZ 1 CORONER I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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. 3 INVESTIGATION and INQUEST On 23rd May 2014 I commenced an investigation into the death of Cerith Wyn Pugh then aged 62 who died on 20th May 2014. The investigation concluded at the end of the inquest on 27th July 2016. The conclusion of the inquest was a narrative one. The deceased had disordered liver function tests from January 2014 onwards. They remained disordered in March 2014. Despite this the deceased was not admitted as an inpatient following his treatment for an orthopaedic problem in March 2014 and no MRCP (magnetic resonance cholangio-pancreatography) procedure was carried out on him as an inpatient. An MRCP would have revealed the presence of gallstones blocking the deceased’s bladder and common bile duct. This would have led to an invasive procesure to remove the gallstones. The medical cause of death was: Ia multi-organ failure b ischaemic bowel disease II cholelithiasis, mechanical jaundice 4 CIRCUMSTANCES OF THE DEATH (1) On 29th March 2013 Cerith Wyn Pugh underwent surgery for a bowel obstruction. (2) His recovery was slower than anticipated and on 18th April 2013 suffered a cardiac arrest and underwent further surgery. (3) A CT scan indicated the possible presence of a stone in the bile duct and an ERCP was undertaken. Mr Pugh was subsequently discharged from hospital. He remained in poor health and there were further readmissions. (4) Mr Pugh was readmitted to hospital in March 2014 following a fall. His blood tests now showed a significantly disordered liver function. Liver function tests were requested but the request was declined for reasons of “demand management” as a previous report was issued less than three days previously. (5) The test results were not acted upon and Mr Pugh was subsequently discharged from hospital. Expert advice received at inquest suggested Mr Pugh should 1 have remained in hospital for further treatment. (6) Mr Pugh was readmitted in May 2014 when he started to bleed from his ilieostomy. (7) Cerith Wyn Pugh passed away on 20th May 2014. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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: That referrals to consultants at Withybush General Hospital are routinely being dealt with by middle grade doctors and, if in the opinion of the middle grade doctor, the matter then needs a referral to a consultant only then is the matter passed to a consultant. All consultant referrals should be seen by consultants in the first instance. Expert evidence received at the inquest described this practice as not being best practice. That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis tests had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 the 21 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person: 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. 2 9 Dated 27 July 2016 Signed: J M Layton 3
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.
Mr J M Layton Senior Coroner Town Hall Hamilton Terrace Milford Haven Pembrokeshire SA7 3JW By E-mail: hmepembs1@pbicannect.com Dear Mr Layton REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - CERITH WYN PUGH Thank you for your report into the death of Cerith Wyn Pugh. As a result of your concems we have issued your redacted report to the Hospital Directors (lead doctors) in each of the four acute hospitals and through them we have asked each consultant to review their practice and to ensure that consultant to consultant referrals are directly reviewed by the consultant or that the review involves proactive delegation where appropriate, and consultant supervision. Some of our services are led by a single handed consultant on a particular site and this does provide some challenges when this individual is on leave. We are actively looking at the process we need to put in place in these cases so that specialist advice can always be accessed either by ar: alternative consultant on site, or a similar specialist on a different site. We have also reminded medical staff that where test requests are made on clinically justifiable grounds these should be undertaken regardless of guidance regarding repeating tests and in the event of an investigation being declined by a provider the matter must be discussed with the Consultant whose team has ordered the request. | hope this letter addresses the concerns that you identified in your report but if you require further information please do not hesitate to contact me. Yours sincerely StU hew- Steve Moore Chief Executive
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