Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0372, written 20 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 | 20 Oct 2016 |
|---|---|
| Reference | 2016-0372 |
| Deceased | Colin Garth |
| Coroner | John Pollard |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Bolton NHS Foundation 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.
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: Dr Jackie Bene, CEO Bolton NHS Foundation Trust, Minerva Road, Farnworth, Bolton BL4 OJR CORONER I am John Pollard Assistant Coroner, for the Coroner Area of Manchester West 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. INVESTIGATION and INQUEST On the 23" June 2016 I commenced an investigation into the death of Colin Garth, born on the 1% May 1963. The investigation concluded at the end of the Inquest on the 20" October 2016. The Medical Cause of Death was: 1a Sepsis 1b Hickman Line Infection and Pneumonia 1c Disseminated Colonic carcinoma 2. Ischaemic Heart Disease The conclusion of the Inquest was Misadventure. CIRCUMSTANCES OF THE DEATH On the 5" May 2016 the deceased was diagnosed with colon cancer. He was operated on, on the following day and on the 10" May a Hickman line was inserted. He was discharged from hospital knowing that he was terminally ill. He was readmitted on the 18" June and he died on the 19" June at the Royal Bolton Hospital. CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: A. During the course of the evidence I was told that when patients are discharged from the hospital with a Hickman or central line in situ, they are not furnished with any guidance booklet or sheet as to how the said line should be monitored, cleaned, flushed etc. It is clearly desirable that they should be as well informed as passible and I therefore consider that the provision of such written advice should be considered. B. Whilst I was satisfied that the Trust does have a clear Policy as to the provision of and use of such lines, there was clearly a lack of knowledge of this policy even amongst quite senior staff members. There should be consideration given to a proper continuous programme of information and education for ALL staff. C. In evidence I was told that at one point the syringe driver (or the extension from it) became blocked and ceased to deliver the fluid as intended by the doctors. This is a fault which can happen in the best of all worlds. What concerned me greatly, however, was that the machine did not sound any bleep or alarm to indicate that it was faulty and having cleared the blockage, the nurse then reconnected the same machine rather than referring it for repair/replacement. There was a very clear need for education of the staff as to how important it is to ensure that all machines are operating properly and safely. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I 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 the 15" December 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (EEE © cartr’s wite on behalf of the family 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 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. lrveactesois 20° October 2016 Signed () De —~ Johr
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.
RECEIVED 20 DEC 2016 aaaassanme 2 Sa Telephone: INHS' E-mail: Bo lton Bolton NHS Foundation Trust Our Ref: JB/AW/1.002065 Minerva Road Your ref: JP/YD/2111-2016 Farnworth Bolton BL4 OJR www. boltonft.nhs.uk 14 December 2016 Mr John $ Pollard Assistant Coroner Manchester West Paderborn House Howell Croft North Bolton BL1 1QY Dear Mr Pollard Colin Garth — Deceased Regulation 28 Report to Prevent Future Deaths 1 am writing in response to your Regulation 28 Report issued following the Inquest into the death of Colin Garth which concluded on 20 October 2016. May | take this opportunity to extend my sincere condolences to the family of Mr Garth for their loss. | am now in a position to respond to your concerns as outlined in Section 5 of your report as follows: Section 5 (A) | am sorry to learn that during the course of establishing how Mr Garth came about his death you heard evidence that when patients with a Hickman or other central line in situ are discharged from hospital they are not provided with any guidance booklet or information sheet as to how the aforementioned line should be looked after. | would like to assure you that all our patients with central lines in situ, who are looked after by the oncology and haematology teams are provided with an information leaflet created by Macmillan Cancer Support. This provides an explanation as to what the line is, how to care for it in addition to identifying any potential problems with the line. However, as this leaflet contains the Macmillan logo, it is not appropriate to provide the same leaflet to our patients who have central lines in situ but are not oncology or haematology patients. As such, a new generic leaflet is being developed, based on the Macmillan leaflet and | expect this will be available to all patients with central lines following completion of the Trust’s internal approval process by the end February 2017. Section 5 (B) ! was disappointed to learn that despite the Trust having a clear Policy relating to the use of central lines, and in particular where a line infection is suspected, that staff demonstrated a lack of knowledge around this. As a result of this the Governance Leads and Practice Educators for each of the Divisions within the Trust are embarking on a programme of continuous education for all clinical staff which will include raising the awareness of the Policy in addition to the overall management of central lines. As part of this process, the Deputy Director of Infection Control is currently reviewing the Policy in order to provide further clarity on the management of line infections. The amended Policy is due to be approved at the next Infection Control Committee in January 2017. Section 5 (C) Again, | was extremely disappointed to hear that a member of staff continued to use a piece of medical equipment when a fault should have been identified which should have resulted in the equipment being taken out of use immediately. The Trust has a very clear Medical Devices and Equipment Policy which describes in detail what action staff should take when using medical devices. In particular, Section 9(1) describes the responsibility of staff to report faults relating to medical devices via the Trust incident reporting process and furthermore, Section 10 (1) deals with the responsibilities of the user of the medical equipment to ensure that it has been checked prior to use and damaged equipment is not used for patient care. | would like to assure you that we are currently engaged in a Trust wide programme of training relating to management of medical equipment which incorporates actions we expect staff to take when equipment is faulty or there is a suspicion of a fault. The Divisional Governance Leads report progress on this training on a quarterly basis to the Clinical Governance and Quality Committee who will retain overall scrutiny on progress. | hope that my response detailed above has provided you with assurance that the Trust has the necessary systems and processes in place to ensure that all members of staff continue to be aware of the management of central lines in addition to the appropriate management of medical equipment. Please do not hesitate to contact me in the event you require any further assistance. Yours sincerely fila Dr Jackie Bene Chief Executive N
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