Prevention of Future Deaths reports · 2016
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 report | 26 Oct 2016 |
|---|---|
| Reference | 2016-0382 |
| Deceased | Alfie Rose |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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
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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