Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0315, written 5 Sep 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Sep 2016 |
|---|---|
| Reference | 2016-0315 |
| Deceased | Imad Hassan |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 !S BEING SENT TO:
EE Medical Director at Cardiff & Vale Health Board
HR Medical Director at ABMU Health Board
GE Medical Director at Cwm Taff Health Board
Chief Coroner
(NOK)
Welsh Health Specialised Services Committee
. Rebecca Evans, Minister for Health & Social Services
CORONER
NOOPSUNS
{am Graeme Hughes, Assistant Coroner, for the coroner area of South Wales Central.
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 the 20" April 2016 | commenced an investigation into the death of Dr Imad Hassan.
The investigation concluded at the end of an inquest on the 16" August 2016. The
conclusion of the inquest was that: "On the 17" April 2016 the deceased suffered an out
of hospital cardiac arrest following a heart attack. He was resuscitated and diagnosed
with having sustained an ST Myocardial infarction. Remaining clinically unstable he was
taken to the nearest hospital, Prince Charles, Merthyr Tydfil. Treatment partially
stabilized his condition to the extent that transfer to another hospital for a rescue PCI
Intervention procedure was not clinically indicated. Even if a rescue PCI Intervention
procedure had been indicated, there was no critical care capacity (at the time) to
undertake this, at UHW Hospital, Cardiff or Morriston Hospital, Swansea”.
4 | CIRCUMSTANCES OF THE DEATH
On the evening of the 17'" Apri! 2016 Dr Hassan suffered an (out of hospital) heart
attack and went into cardiac arrest. He was resuscitated by the emergency services at
the scene and taken to Prince Charles Hospital for urgent medical attention. His
condition was partially stabilised and there were discussions between the clinicians at
Prince Charles Hospital, University Hospital of Wales in Cardiff and Morriston Hospital in
Swansea as to Dr Hassan’s suitability for Percutaneous Coronary Intervention (PC!) to
be performed as at either Morriston Hospita! or UHW in Cardiff. Dr Hassan suffered a
further Cardiac Arrest at Prince Charles Hospital and died 04:35hrs on the 18'" April
2016.
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concerns.
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. —
[BRIEF SUMMARY OF MATTERS OF CONCERN]
1) In the event that a patient at Prince Charles Hospital is deemed suitable for PCI
there is currently no formal back up plan in place, to enable the PCI to proceed,
should UHW in Cardiff or Morriston Hospital in Swansea be unable to accept
that patient.
2) In such circumstances, a patient meeting the criteria for PCI is unable to
undergo that procedure, increasing the risk of his/her death, until there is such
capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI.
3) As per the evidence of EEE given at inquest, an agreed short term
pathway needs to be put in place to access adult critical care beds outside
Wales and a bed management pathway put in place.
4) There is currently no agreed pathway for an unconscious STEM! patient
requiring PCI in tertiary services as there is currently for conscious patients with
STEMI. Although in the case of Dr Hassan transfer to another hospital for a
rescue PCI was not clinically indicated, that may not necessarily be the case in
the future, particularly, in a patient who has had a short period of
unconsciousness and a PC! is clinically indicated.
5) In similar circumstances as pertained on the evening prior to / the morning of Dr
Hassan’s death such a patient (as described in 4)) maybe deprived the
opportunity of undergoing rescue PCI due to lack of capacity at either UHW in
Cardiff or Morriston in Swansea.
ACTION SHOULD BE TAKEN
in my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action.
In particular, formulating and implementing a formal backup pian in the event that both
UHW and Morriston Hospitals are unable to accept a patient for PC! and by the creation
and implementation of an agreed pathway for the unconscious STEMI patient requiring
PCI in tertiary services.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 1: November 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, Cardiff & Vale Medical Director,
ABMU Medical Director, Cwm Taff Medical Director, Welsh Health Specialised Services
Committee, Minister for Health & Social Services and the family who may find it useful or
of interest.
{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 cor: ~at the time of your
response, about the release or the publication of a jonse by\the Chief Coroner.
5" September 2016
M Assistant Coroner
2 responses 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.
Your ref/eich cyf: lA ON G IG Bwrdd lechyd Prifysgol Our ref/ein cyf: Anes neastN3 CYMRU Date/Dyddiad: lovember Hye NHS SSE Tel/ffan: 01443 744848 \OZ University Health Board Fax/ffacs: 01443 744888 WALES Email/ebost: Dept/adran: Chair and Chief Executive Mr Graeme Hughes Her Majesty’s Assistant Coroner for South Wales Central Area Coroner’s Court Rock Grounds First Floor Aberdare CF44 7AE Dear Mr Hughes, Re: Regulation 28 Response: Further to the issuing of the Regulation 28 dated 26" August 2016, following the inquest into the sad death of Dr Imad Hassan (deceased on 18" April 2016). Cwm Taf University Health Board has been working with WHSSC (Welsh Health Specialised Services Committee) as the commissioner of specialist Cardiology services, and the Provider Units in Cardiff and Swansea to develop an interim solution pending the completion of a comprehensive pathway for this patient group in the summer of 2017. The attached joint letter represents the agreed interim position between the respective organisations which will be further developed for the next meeting of the Joint Committee later this month. We hope that these arrangements are satisfactory and would emphasise our commitment to ensuring that in the future our services can consistently meet the expected standards. A local corrective Action Plan for improvement was developed and will be shared with clinical colleagues in Cardiology and Critical Care as well as Emergency Departments and Heads of services. (Appendix 1). T would like to convey again my deepest sympathy and sincere apologies to Dr Hassan’s family for the failings identified. If you require any additional Information or clarification please does not hesitate to contact me. Kind regards Mr Kamal Asaad Medical Director CWM TAF University Health Board Return Address: Ynysmeurig House, Unit 3, Navigation Park, Abercynon, CF45 4SN Chair/Cadeirydd: Dr C D V Jones, CBE Chief Executive/Prif Weithredydd: Mrs Allison Williams Cwm Taf Health Board is the operational name of Cwm Taf Local Health Board/Bwrdd Iechyd Cwm Taf yw enw gwelthredol Bwrdd lechyd Lleol Cwm Taf
KBs! . Your ref/eich cyf: AB/CE/5839 a GIG Puyyligor Gwasanaethau lechyd Our ref/ein cyf: Inc16-08-Reg28 os, Cysnu | Arbenigol Cymru (PGIAC) Date/dyddiad: 12 December 2016 i 7 NHS | welsh Health speciaised Tel/ffén: 01443 443443 ext 8149 d WALES § Services Committee (WHSSC) Fax/ffacs: 02920 807854 Email/ebost: sian.lewis100@wales.nhs.uk Mr Graeme Hughes H M Asst Coroner Rock Grounds First Floor Aberdare CF44 7AE Dear Mr Hughes Further to your letter of 16° November 2016, I am writing to confirm the arrangements for the management of patients who suffer an out of hospital cardiac arrest and are not admitted to a hospital which offers primary percutaneous coronary intervention (PPCI). We have confirmed with the United Hospitals University Bristol Trust that they will take patients in the event there is insufficient critical care capacity in South Wales. The transfer of care will be facilitated by the usual regional PPCI centre both for patients in the South West and the South East of Wales. In addition as we outlined in our original response there is work underway on an all Wales basis to agree a longer term strategy for these patients. Yours sincerely Prod wos Dr Sian Lewis Acting Medical Director Welsh Health Specialised Services Committee Pwyligor Gwasanaethau Iechyd Arbenigol Cymru 3a Caerphilly Business Park 3a Parc Busness Caerffili Caerphilly Caerffili CF83 3ED CF83 3ED Chair/Cadeirydd: Mrs Ann Lioyd, CBE Acting Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Dros Dro Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Mr Stuart Davies
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