Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0350, written 10 Oct 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 Oct 2016 |
|---|---|
| Reference | 2016-0350 |
| Deceased | Ann Hardman |
| Coroner | Caroline Sumeray |
| Coroner area | Isle of Wight |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Isle of Wight NHS Trust |
| 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 THIS REPORT IS BEING SENT TO: 1. Karen Baker, Chief Executive of the Isle of Wight NHS Trust 1 CORONER I am Caroline Sarah Sumeray, Senior Coroner for the Coroner Area of the Isle of Wight. 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 January 2015 I commenced an investigation into the death of Ann Hardman, aged 73. The investigation concluded at the end of the inquest on 6th October 2016. The conclusion of the inquest was Natural Causes. The medical cause of death was found to be: 1a Pulmonary Thromboembolism 1b Thrombosis of the Deep Veins of the Left Calf 1c 2 4 CIRCUMSTANCES OF THE DEATH 1) Ann Hardman presented at her GP’s practice on 13th January 2015 complaining of a three-week history of a painful left calf and cough. She was examined and found to have a swollen left calf, but her chest examination was normal. She was apyrexial and had oxygen saturation of 97% and a regular pulse of 70bpm. A D-Dimer test was undertaken which gave a positive result. Her Wells Score was 2 due to her left calf being swollen by more than 3cm than her right leg, and because there was pitting oedema on her left leg. Her GP gave her an injection of Clexane and sent her directly to St Mary’s Hospital for an ultrasound scan of her left leg to rule out a deep vein thrombosis. 2) Later that day at St Mary’s Hospital, she was scanned by an ultrasound sonographer who had difficulty carrying out the scan effectively as Mrs Hardman 1 was a morbidly obese lady, resulting in a poor quality scan of her leg. The ultrasound sonographer reported back to her GP as follows: “Suboptimal scan due to technical limitations associated with the patient’s build. The common femoral vein, superficial femoral vein, popliteal vein and deep calf veins were assessed and no evidence was seen of an acute DVT on today’s scan.” Evidence heard at the Inquest from the sonographer revealed that the language that she had used was ambiguous inasmuch as the “technical limitations” referred to the difficulty carrying out an effective scan due to Mrs Hardman’s obesity, and that “no evidence was seen of an acute DVT” meant that a DVT couldn’t be seen, but due to Mrs Hardman’s obesity, it was impossible to be certain that there definitely was no DVT in her left leg. 3) Mrs Hardman had no further dealings with her GP’s practice before 20th January 2015. 4) On 20th January 2015, Mrs Hardman contacted her GP’s practice complaining of chest pain and requesting an appointment. The receptionist told her to dial 999 or offered to do it for her. Mrs Hardman declined this advice and shortly thereafter she was found dead at home by her daughter. 5) Evidence heard at the Inquest revealed that various protocols had changed since Mrs Hardman’s death, including that it is now the practice after a negative ultrasound scan for a DVT to rescan the patient 6-8 days later, and that this new practice had found 5 previously undiagnosed DVTs in patients who had previously been given a negative ultrasound scan thereby saving 5 lives, however this relies on the patient revisiting their GP and being given another referral form for a scan at St Mary’s Hospital. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters 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: – 1. I am concerned that when there is a negative scan for a DVT at St Mary’s Hospital, the current protocol relies on the patient returning to their GP and being given another referral form for a further scan 6-8 days later. It was accepted that a better system would be one whereby the patient was automatically told to return for a further scan a week or so later by the ultrasound department, subject to the patient’s GP cancelling this scan, based 2 on their clinical judgement of any review of the initial scan and/or any further examination of the patient. This would remove the chance of patients failing to be told to re-attend for a further scan. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation 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 21st November 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 Persons: the family of Ann Hardman. 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. 9 H.M. Senior Coroner – Isle of Wight 10th October 2016 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.
Isle of Wight INHS| NHS Trust Pad St Mary's Hospital Isle of Wight NHS Trust Newport Isle of Wight 21 November 2016 Mrs C. Sumeray H.M. Coroner. Isle of Wight Coroners Office RSKC-XJZG-JKGZ Seaclose Offices NEWPORT Isle of Wight PO30 2QS Dear Mrs Sumeray Regulation 28 Report to Prevent Future Deaths | write to respond to your letter of 10 October 2016 following the inquest of Mrs Ann Hardman. | understand that Consultant Radiologist attended the inquest with J enc he had taken your recommendations further within the Trust. | am therefore very pleased to report that we have implemented the following system in line with your suggestion: e Any patient with a D-Dimer positive blood result but a negative Ultrasound scan now has a repeat scan booked by the Ultrasound department 6-8 days from the time of the negative scan. If a patient does not attend this second scan the Ultrasound Department will contact the relevant General Practitioners (GP) Surgery to inform them of this non- attendance. HS has informed me that he had written a joint letter with PF General Practitioner to all Island GP’s to inform them of this new procedure. Thank you for highlighting this matter to me and | am pleased that we are able to work with you to improve healthcare on the Isle of Wight. Yours sincerely Karen Baker Chief Executive Officer v7 SMOKEFREE Isle of Wight
See every Prevention of Future Deaths report matching Isle of Wight NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.