Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0410, written 9 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Nov 2016 |
|---|---|
| Reference | 2016-0410 |
| Deceased | Simon Harper |
| Coroner | Sarah Slater |
| Coroner area | South Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sheffield Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Secretary of State for Health
1 | CORONER
Sarah Louise Slater assistant coroner, for South Yorkshire (West)
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 ({Investigatory) Regulations 2013.
(1) Where -
a. A senior coroner has been conducting an investigation under this Part into a
person’s death and
b. Anything revealed by the investigation gives rise to concern that circumstances
creating a risk or other deaths will occur, or will continue to exist, in the future,
and
c. In the coroner’s opinion, action should be taken to prevent the occurrence or
continuation of such circumstances, or to eliminate or reduce the risk of death
created by such circumstances, the coroner must report the matter to a person
who the coroner believes may have the power to take such action.
(2) A person to whom a senior coroner makes a report under this paragraph must give
the senior coroner a written response to it.
(3) A copy of a report under this paragraph, and of the response to it, must be sent to
the Chief Coroner
INVESTIGATION and INQUEST
On 15" March 2016 | commenced an investigation into the death of Mr Simon Timothy
Harper. The investigation concluded at the end of the inquest on 28'" October 2016. The
conclusion of the inquest was the Mr Simon Timothy Harper died from;
1a) Multiple Organ Failure
1b) Pneumonia
1c) Alcohol related liver disease
A narrative conclusion was recorded as follows:
Mr Harper was admitted to the Northern Generali Hospital on the 6" March 2016 with
jaundice and abdominal distention. His condition deteriorated and he was transferred to
the intensive care unit on the 7" March 2016. However, during the transfer Mr Harper's
oxygen cylinder was not turned on and it is likely this lead to him suffering a cardiac
arrest whilst on route.
Mr Harper was successfully resuscitated but he continued to deteriorate and died on the
9" March 2016. It is not possible to state what effect, if any, this cardiac arrest has had
on Mr Harper’s death.
CIRCUMSTANCES OF THE DEATH
Mr Harper was admitted to the Northern General Hospital on 6" March 2016 with
jaundice and abdominal distention. On the 7" March 2016, Mr Harper suffered liver
failure, kidney failure and respiratory failure. Mr Harper was receiving oxygen via a non-
rebreathe mask from. the main hospital wall supply to support his lung function. Later
that evening the patient underwent a Critical Care Review who agreed a transfer to the
General Intensive Care Unit. In order to transfer Mr Harper safely a portable oxygen
supply was required and this was supplied by the portering department. It is the
responsibility of nursing staff to connect the cylinder to Mr Harper. On route to the
General Intensive Care Unit the patient, Mr Harper suffered a sudden deterioration and it
was noticed that the portable oxygen cylinder had not been turned on. Mr Harper
suffered a cardiorespiratory arrest to which resuscitation attempts were successful. He
was admitted to the General Intensive Care Unit shortly after midnight at which point he
was deeply comatose and anuric. On 9" March 2016 treatment was withdrawn and
death occurred at 1800.
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving raise 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. —
The inquest heard that in November 2010 the act of connecting a patient to an oxygen
cylinder for transfer was reassigned from porter staff to nursing staff.
Upon the reassignment of the task, one session of training was provided by an external
company to a small number of nursing staff who were on duty at the time. There is no
record regarding the contents of the induction/training or who was present at the time. In
addition, the Trust confirmed that since that date there has been no formal training and
they have relied on ‘peer to peer’ training. In addition, no register of individuals trained
or content of training is documented. There is no record of who has and has not
received relevant training and no audit is in place to assess the appropriateness of this
‘on the job’ his training.
The inquest heard that the nurse responsible for connecting the patient to the oxygen
cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the
cardiorespiratory arrest although it was accepted no-one could be certain of this.
The Secretary of State for Health is asked to consider whether it is appropriate for
training to be provided and documented regarding the use of portable oxygen cylinders
for patients. The implementation of a Transfer of Patients Policy should also be
considered as those available did not cover this issue.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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 26" January 2017. 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
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons;
The family of Mr Harper
The Chief Executive, Sheffield Teaching Hospitals NHS Foundation Trust
lam 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™ November 2016 Louise Slater
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