Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0369, written 17 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 | 17 Oct 2016 |
|---|---|
| Reference | 2016-0369 |
| Deceased | Vinod Kumar |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. do New Cross Hospital, Wolverhampton, West Midlands, WVIO OQP CORONER am Zafar Siddique. Senior Coroner, for the coroner area of the Black Country 2 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 3 INVESTIGATION and INQUEST On the 22 August 2016 I commenced an investigation into the death of the late Mr Vinod Kumar. The investigation concluded at the end of the inquest on 12 October 2016. The conclusion of the inquest was a short narrative conclusion of accidental death. The cause of death was la b c Multi Organ Failure Group A Streptococcus Septic Shock Necrotising Fasciitis secondary to laceration sustained from fall + RCUMSTANCES OF THE DEATH I) Mr Kumar was a very active and healthy family man who attended the gym and kept fit. r aro rd the O flu ike sy pt / gust 2016 he was orplai for t r this esulted ‘ns Urusua I g of fecli ig urwe with tak og time of work The following day he had a fail at home and sustaned a graze to his rght arm elbow. Hs codton ccntimjec m dece and e attended Ne Cross H o t 2 afre ed 9 A r Cv o Viu a see d al a n e g v a r in t’e Accdent ann Emergency Department he was ntiallv seen b a Triage nurse who categorsed him ha o y n a eve 4 (ieast urgent and to K h s and a o len/p irful a d g f v He ae arar at rig , a I to a ar 9 c”i t a a se c was extremely l and in muftorqanfaure vii) His condition declined further and sepsis secondary to necrotising fasciitis was dag nosed vni) Despite surgical intervention to remove the infected tissue he died shortly after the surgery on the 10 August 2016 ix On the balance of probability the likely source of necrotisi g fasciitis was the graze on the arm injury 5 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 uriess action s taken. in the crcumstances it is my statutory duty to report to you The MATTERS OF CONCERN are as follows — 1. Evidence emerged during the inquest that when he was seen initially by the Triage nurse too much emphasis and reliance was placed on the significance of the fall/trauma Evidence of potential infection (swelling to his arms) resulted in no further observations or blood tests done until some three hours later that 2 Evidence from the A and E Consultant emerged from the inquest which suggested that it would have been good practice to keep the patient under further observation before determining his terms of categorisation level of priority in 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 1. You may wish to consider reviewing your polcy!guideIines in respect of the current sepsis policy, particularly in light of what happened to Mr Kumar. Evidence of swelling to his arms and the history given may have triggered an earlie blood tcst and observations YOUR RESPONSE You are under a duty o respono to th s rport within e days of the date of tf is eport na e c b 2 by o c o ay x. d e r r5pr9c must nar deta 0’ actn akr or proposed o oO rsco ue a a v racon no cc ak settn COPIES and PUBLICATION l have sent a cony of m report to the Chef Corone and to the fciowng lnteresred Person rvirs Kmar [iL1 PRr)TE( T or of interest You may make representations to me the coroner at the time of your response about the re’ease or the pubication of your response by the Chief Coroner Th 17 October 2016 Mr Z Siddique Senior Coroner Black Count!y Area
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.