Prevention of Future Deaths reports · 2016

Alfie Rose

Regulation 28 report to prevent future deaths, reference 2016-0382, written 26 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report26 Oct 2016
Reference2016-0382
DeceasedAlfie Rose
CoronerLouise Hunt
Coroner areaBirmingham and Solihull
CategoryChild Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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. Dudley Group of Hospitals NHS Foundation Trust
2. University Hospitals Birmingham NHS Foundation Trust
1 CORONER
I am Louise Hunt, Senior Coroner for Birmingham and Solihull
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 22/06/2016 I commenced an investigation into the death of Alfie Rose aged 17. The investigation
concluded at the end of an inquest on 26th October 2016. The conclusion of the inquest was:
Alfie died from complications of obstructive hydrocephalus. Earlier detailed MRI scan, admission and
treatment at Queen Elizabeth Hospital neurosurgical unit on 16/05/16, 27/05/16 and the morning of
06/06/16 would, on balance, have avoided his death.
4 CIRCUMSTANCES OF THE DEATH
The deceased had suffered from hydrocephalus as a child. He had not required any treatment during
childhood. On 02/05/16 he presented to Russell’s Hall Hospital complaining of a headache for two weeks.
Scans revealed generalized ventricular dilatation compatible with likely arrested hydrocephalus. An
ophthalmology examination found evidence of papilloedema resulting in an urgent referral to
outpatients at Queen Elizabeth Hospital in Birmingham. He was seen in the neurosurgery hot clinic at
Queen Elizabeth Hospital on 16/05/16 when doctors advised he should be admitted for further
assessment and treatment. He refused admission so arrangement was made for further follow up in out
patients clinics. On 27/05/16 he presented to his GP with headache of increasing severity. He was
referred to Russell’s Hall Hospital where further scans were undertaken which were unchanged from
before. He was discharged home. He presented to Russell’s Hall hospital emergency department at
11am on 06/06/16 complaining of further headaches. An MRI scan was undertaken which was
unchanged from before and his symptoms resolved so he was discharged home. He returned to the
emergency department at 22.22 complaining of a headache and vomiting. He was taken to the high
dependency side of the department. At approximately 00.30 he had a sudden deterioration and
respiratory arrest requiring full resuscitation. A further CT scan was undertaken confirming severe
hydrocephalus. He was transferred as an emergency to Queen Elizabeth Hospital in Birmingham leaving
at 04.38 and arriving at 05.34. An external ventricular drain was inserted immediately on arrival. Further
assessment confirmed extensive brain infarction indicating a severe brain injury. He died at 11.33 on
09/06/16 following organ donation.
Based on information from the Deceased’s treating clinicians, the medical cause of death was
determined to be:
BRAIN STEM DEATH
OBSTRUCTIVE HYDROCEPHALUS
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 unless action is taken. In the circumstances it is my statutory
duty to report to you.
The MATTERS OF CONCERN are as follows. –
1. There was poor communication between both hospitals in relation to Alfie’s condition and care.
Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall
Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of
06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both
Trusts need to look at their communication systems and identify areas for improvement and to
clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system
entries cannot always be seen.
2. Education. It is important the clinicians in outlying hospitals understand how neurological
referrals should be made and when. Better guidance and education is needed for outlying
hospitals.
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.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd
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.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:‐
The family
LOCAL SAFEGUARDING BOARD (as the deceased was under 18)
NHS England
CQC.
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 26/10/2016
Louise Hunt Senior
Coroner
Birmingham and Solihull

Responses

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.

Response from The Dudley Group NHS Trust (PDF)
The Dudley Group INHS|

NHS Foundation Trust

Dudley
29 VEL Lb | West Midlands

R EC E IV E D | Russells Hall Hospital

21 December 2016

DY1 2HQ

PRIVATE & CONFIDENTIAL
Mrs L Hunt

HM Senior Coroner

Birmingham and Solihull Areas
Birmingham Coroner’s Court

50 Newton Street

Birmingham

B4 6NE

Dear Mrs Hunt

This letter is in response to the Regulation 28 Report to Prevent Future Deaths Issued
by Mrs Louise Hunt, Senior Coroner for Birmingham and Solihull, on 26" October,
2016 following the inquest into the death of AR, date of birth 25" March 1999, The
Matters of Concern raised in the Report were:

1. There was poor communication between both hospitals in relation to Alfie’s
condition and care. Details of his neurosurgical review on 16/05/16 were not
made available to Russell’s Hall Hospital. His clinical condition was not relayed
to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed
opportunities to transfer him back to QE for treatment. Both Trusts need to look
at their communication systems and identify areas for improvement and to
clarify if the NORSE system is effective. I heard evidence to suggest that all
NORSE system entries cannot always be seen.

2. Education. It is important the clinicians in outlying hospitals understand how
neurological referrals should be made and when. Better guidance and education
is needed for outlying hospitals.

Norse is a secure messaging system that was developed initially to provide a more
effective method of communicating with the Neurosurgical team about patients who
required a neurosurgical opinion. Before Norse was developed contact with
Neurosurgery at QEHB was via telephone. The on call registrar would spend the
majority of their time answering the phone, often with unacceptable delays for the
referring clinician and the patient. The Norse system has replaced the majority of
those phone calls and has improved access to the Department. It allows a referral to
be made and a response to be given, providing an audit trail that was not previously
available.

A Teaching Trust of

Chair: Jenni Ord the University of Birmingham Acting Chief Executive: Dr Paul Harrison

We believe that Norse is an effective tool for communication between secondary and
tertiary specialties which has improved access to specialties at QEHB and enhanced
clinical governance around that process.

It is important to reflect on the effectiveness of any system when there has been a
significant clinical incident. To that end the following meetings have been held to
identify areas of concern that could be improved:

10" November, 2016: Round Table meeting at Queen Elizabeth Hospital Birmingham
(QEHB”).

5" December, 2016: Meeting between clinical staff from Russell’s Hall Hospital
(“RHH”) and QEHB.

Issues Identified:

1. The letter written following AR’s attendance at the Neurosurgical Hot Clinic
was written to the General Practitioner, but not copied to the patient or the
referring doctor from RHH. There was a unacceptable 27 day turnaround for
the letter.

2. AR declined admission from the Hot Clinic. His case was discussed with a
consultant, but he wasn’t reviewed by a consultant.

3. Visibility of patients on Norse at the referring centre is limited to the person
who initiates the referral. There are exceptions. The case can be shared with
another user or users, which did not happen in this case. There should be one or
more ‘super users’ at the referring centre who have oversight of all activity on
Norse. This is not currently in place at RHH.

4. There are difficulties obtaining information on patients seen at QEHB when
they attend other hospitals as emergencies.

5. There is no Norse Users’ Group
6. It was noted that there are no guidelines for the management of patients known

to have hydrocephalus in the emergency setting.

A detailed action plan has been developed (attached to this letter) and the actions have
been agreed by both UHB and DGFT. We have commenced on the delivery of these
actions and recorded our progress on the action plan for you information.

Should you have any questions on the action plan or require any further information
then please do not hesitate to contact myself or the Trust Chief Executive Paul
Harrison.

Yours sincerely

Medical Director
Response from University Hospitals Birmingham NHS Trust (PDF)
University Hospitals Birmingham

NHS Foundation Trust

Trust Headquarters
Level 1

Director of Corporate Affairs Queen Elizabeth Hospital Birmingham
. Mindelsohn Way
Tel: P| Edgbaston
Fax : Birmingham
B15 2GW

Rot

Tel: 0121 371 2000

21 December 2016

Mrs L Hunt

HM Senior Coroner
Birmingham and Solihull Areas
Birmingham Coroner's Court
50 Newton Street

Birmingham

B4 6NE

Dear Mrs Hunt

This letter is in response to the Regulation 28 Report to Prevent Future
Deaths Issued by Mrs Louise Hunt, Senior Coroner for Birmingham and
Solihull, on 26 October, 2016 following the inquest into the death of AR, date
of birth 25 March 1999.

The Matters of Concern raised in the Report were:

1. There was poor communication between both hospitals in relation to
Alfie's condition and care. Details of his neurosurgical review on
16/05/16 were not made available to Russell's Hall Hospital. His clinical
condition was not relayed to QE hospital on 27/05/16 or morning of
06/06/16. These were vital missed opportunities to transfer him back to
QE for treatment. Both Trusts need to look at their communication
systems and identify areas for improvement and to clarify if the NORSE
system is effective. | heard evidence to suggest that all NORSE system
entries cannot always be seen.

2. Education. It is important the clinicians in outlying hospitals understand

how neurological referrals should be made and when. Better guidance
and education is needed for outlying hospitals.

Chair: Rt Hon Jacqui Smith Chief Executive: Dame Julie Moore

Norse is a secure messaging system that was developed initially to provide a
more effective method of communicating with the Neurosurgical team about
patients who required a neurosurgical opinion. Before Norse was developed
contact with Neurosurgery at QEHB was via telephone. The on call registrar
would spend the majority of their time answering the phone, often with
unacceptable delays for the referring clinician and the patient. The Norse
system has replaced the majority of those phone calls and has improved
access to the Department. It allows a referral to be made and a response to
be given, providing an audit trail that was not previously available.

We believe that Norse is an effective tool for communication between
secondary and tertiary specialties which has improved access to specialties at
QEHB and enhanced clinical governance around that process.

It is important to reflect on the effectiveness of any system when there has
been a significant clinical incident. To that end the following meetings have
been held to identify areas of concern that could be improved:

10 November, 2016: Round Table meeting at Queen Elizabeth Hospital
Birmingham (“QEHB’).

5 December, 2016; Meeting between clinical staff from Russell's Hall Hospital
("RHH") and QEHB.

Issues Identified:

1. The letter written following AR's attendance at the Neurosurgical Hot
Clinic was written to the General Practitioner, but not copied to the
patient or the referring doctor from RHH. There was a unacceptable 27
day turnaround for the letter.

2. AR declined admission from the Hot Clinic. His case was discussed with
a consultant, but he wasn’t reviewed by a consultant.

3. Visibility of patients on Norse at the referring centre is limited to the
person who initiates the referral. There are exceptions. The case can be
shared with another user or users, which did not happen in this case.
There should be one or more ‘super users’ at the referring centre who
have oversight of all activity on Norse. This is not currently in place at
RHH.

4. There are difficulties obtaining information on patients seen at QEHB
when they attend other hospitals as emergencies.

5. There is no Norse Users’ Group

6. It was noted that there are no guidelines for the management of patients
known to have hydrocephalus in the emergency setting.

The actions set out in the attached table have been agreed.

| trust that we have addressed the issues raised.

Yours sincerely

Director of Corporate Affairs

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