Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0287, written 10 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Aug 2016 |
|---|---|
| Reference | 2016-0287 |
| Deceased | Thomas Jordan |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · State Custody related deaths |
| Organisation named | Leeds Teaching 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Head of Healthcare at Her Majesty’s Prison, Leeds. 2. The Medical Director of the Leeds Teaching Hospitals NHS Trust. 1 | CORONER | am David Hinchliff, Senior Coroner, for the coroner area of West Yorkshire (East) 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and reguiations 28 and 29 of the Coroners (investigations) Regulations 2013. 3. | INVESTIGATION and INQUEST On 7" August 2015 | commenced an Investigation into the death of Thomas George Jordan, aged 80 years. The Investigation concluded at the end of the Inquest on 28" June 2016. The Conclusion of the Inquest was:- “Thomas George Jordan was a remand Prisoner at Her Majesty's Prison, Leeds who suffered with a number of chronic medical conditions as befits his age. He became unwell and was admitted to St James’s University Hospital, Leeds where his death was confirmed at 1955 hours on 6” August 2015” The cause of death being:- 1(a) Ischaemic Heart Disease (b) Coronary Artery Atheroma 2 Diabetes Mellitus. Conclusion : Natural Causes 4 | CIRCUMSTANCES OF THE DEATH e Thomas George Jordan was remanded in custody at Her Majesty's Prison, Leeds in April 2015 after breaching his bail conditions. e On the morning of 6” August 2015 his heart rate was fast and irregular. He was therefore admitted to Leeds General Infirmary with central chest pain, breathlessness, fast atrial fibrillation and low blood pressure. He described having felt unwell for the previous three weeks. e Clinically he was dehydrated and showed signs of kidney impairment and severe metabolic acidosis. He was reviewed by a Cardiologist and an ultrasound scan of his heart was performed. Later he was transferred to St James’s University Hospital, Leeds, where his condition deteriorated. e He went into cardiac arrest and despite cardiopulmonary resuscitation his death was confirmed at 1955 hours on 6" August 2015. CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. tn 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) Healthcare staff at the Prison continued to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) | require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation have 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 29" September 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 and to the following Interested Persons, the Head of the Prison Service, the Prisons and Probation Ombudsman and the Chief Inspector of Prisons. | 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. 10” August 2016 DAVID HINCHLIFF Senior Coroner West Yorkshire (Eastern)
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.
care E3 Care UK Hawker House 5-6 Napier Court Napier Road Reading Berkshire RG1 8BW www.careuk.com David Hinchliff, Senior Coroner West Yorkshire (Eastern) Coroner's Office and Court 71 Northgate Wakefield WF1 3BS 28 September 2016 Dear Mr Hinchliff, Inquest touching the death of Thomas George Jordan - Regulation 28 Report I write in response to your Regulation 28 Report dated 10 August 2016. I have also had sight of the letter from Rachel Howitt, Incident and Assurance Manager, Leeds Community Healthcare dated 4 August and your letter of 10 August in response. Further to that correspondence, the Head of Healthcare at HMP Leeds has discussed the above with the Clinical Director for Urgent Care at Leeds Teaching Hospital. The Director has agreed that an electronic summary can be issued with all patients who transfer back to HMP Leeds following discharge from a hospital admission. The Hospital currently send an electronic summary to the registered GP and the process for sending the same to the prison can be incorporated within their system. IT personnel from both the Hospital and Care UK will create a pathway that ensures all summaries are appropriately shared. In the meantime, the Director will ensure that written summaries are provided in a sealed envelope for all hospital discharges and these will accompany the patient back to the prison. I trust that this addresses your concern but please do not hesitate to contact me if I can be of any further assistance. Yours sincerely Company Solicitor Care UK Consultant in Emergency Medicine Clinical Director, Acute Medicine Chair, ATLS UK Emergency Department St James's University Hospital Beckett Street Leeds LS9 7TF Care UK Limited. Registered in England No 1668247 Registered Office: Connaught House, 850 The Crescent. Colchester Business Park, Colchester, Essex C04 9QB
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