Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0387, written 28 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 | 28 Oct 2016 |
|---|---|
| Reference | 2016-0387 |
| Deceased | Alfred Grimshaw |
| Coroner | Michael Singleton |
| Coroner area | Blackburn, Hyndham and Ribble Valley |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Lancashire Healthcare NHS 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer East Lancashire Healthcare NHS Trust Trust Headquarters The Royal Blackburn Hospital Haslingden Road Blackburn BB23HH CORONER Iam Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn & Ribble Valley. 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 9"" day of June 2016 I commenced an Investigation into the death of Alfred Grimshaw aged 93 years. The Investigation concluded at the end of the Inquest which was heard on the 25'" day of October 2016. The conclusion of the Inquest was that Alfred Grimshaw had died from Natural Causes contributed to by a fall followed by surgery. CIRCUMSTANCES OF THE DEATH On the 26" May 2016 Alfred Grimshaw had an unwitnessed fall at the residential care home and was admitted to the Royal Blackburn Hospital. On assessment in the Emergency Department it was noted that since the accident he had been unable to mobilise and that because of his dementia it was not possible to take a history from him. He was admitted onto the acute medical unit but then discharged on the 28" May back to the care home. He was then re-admitted on the 1° June 2016 when x-rays revealed that he had a fractured hip. He underwent surgery but died from bronchopneumonia on the 6" June 2016. CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving arise to concern. In my opinion there is a risk that further deaths will occur unless action is taken. In the circumstances it is my duty to report to you the MATTERS OF CONCERN being as follows: - 1 1044780/2016 Alfred GRIMSHAW (Deceased) 1. O | n being assessed in the emergency department on the 26" May, despite | the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise no x-ray was carried out in : order to rule out the possibility of a fracture to his hip. t 2. On the 27" May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it. 3. On the 27" May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge. 4. On the discharge summary that was printed on the 28" May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any hysiotherapy.” That handwritten note is not signed or dated. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 December 2016. I, the Coroner, may extend this 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 T have sent a copy of my report to the Chief Coroner and to the following interested person, namely: Tam 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. 28 October 2016 Signed by: we ncbetee Xf eacebeestescensee envenes MicHael 3 H Singleton H MSenior Coroner for Blackburn, Hyndburn & Ribble Valley Ne 1€44780/2016 Alfred GRIMSHAW (Deceased)
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.
East Lancashire Hospitals INHS| NHS Trust Enquiries to Trust Headquarters Telephone No Royal Blackburn Hospital Ext: 82845 Haslingden Road Fax: Blackburn Email Pe BB2 3HH 18 January 2017 PRIVATE AND CONFIDENTIAL Mr M JH Singleton Coroner's Office Blackburn Enterprise Centre Furthergate Blackburn BB1 3HQ Dear Mr Singleton Re: Regulation 28 report in relation to the death of Mr Alfred Grimshaw | am writing in response to your Regulation 28 letter of 28" October 2016 in which you identify several specific concerns relating to the care of a specific patient. | apologise for the delay in replying; this is due in part to exceptional clinical workload and delays in obtaining case notes. The case involved a failure to diagnose a fracture of the femoral neck during the initial admission of this patient despite a number of opportunities to do so. This patient was subsequently re-admitted (four days after discharge) and received the correct surgical management but unfortunately suffered post-operative complications. and died. | will deal with each of your concerns in the order you raise them: 4. The failure to perform an x-ray of the hip given the history and clinical findings. | have reviewed the Emergency Department notes of this patient and the clinical picture presented to the Doctor did not suggest a fractured femoral neck as the patient was moving all limbs and not complaining of specific hip pain. An alternative diagnosis to explain the reduced mobility was felt to be more appropriate. 2. The x-ray report of 27" May (abdominal x-ray to exclude intestinal obstruction) failed to report the evident right hip fracture. The Radiologist who undertook this report is currently under restricted practice, and subject to a clinical review. | am unable to comment further on this matter but specific measures have been put in place to ensure that the risk of further errors is reduced. 384. The processes around communication relating to discharges of complex frail patients has been significantly strengthened in the past six months with specific emphasis upon the role of the Multidisciplinary Team. There have also been developments between primary and secondary care to ensure that discharge documentation and transfer of information is improved. Safe Personal Effective CO RERE | would point out that initial statement stated that the discharge summary print out that you refer to was printed on 1* June, whereas your letter suggests 28" May. Having reviewed the case notes if the case that the letter printed out on 28" May does not contain a handwritten note. Itis the copy printed on 1* June which does. | have been unable to identify who wrote this note. As a result of the receipt of this Regulation 28 notice this case has been used as a learning case for teaching of Junior Doctors and used in feedback meetings to the Ward Team involved Yours sincerely le tobe, Deputy Medical Director — Quality & Education Consuitant - Anaesthetics & Critical Care Safe Personal Effective One
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