Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0413, written 14 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 | 14 Nov 2016 |
|---|---|
| Reference | 2016-0413 |
| Deceased | Margaret Wakefield |
| Coroner | Emma Carlyon |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of the Royal Cornwall Hospital, Treliske, Truro 1 | CORONER lam Dr E Emma Carlyon for the Coroner area of Cornwall and the Isles of Scilly 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 (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST Margaret Erskin Hare Wakefield died on 5 February 2016 at the Royal Cornwall Hospital, Treliske, Truro and an inquest was opened on 11 February 2016. The inquest hearing took place on 3 October 2016. The inquest found an Open Conclusion with the cause of death recorded as 1a ischaemic heart disease 1b Severe Coronary Artery Atherosclerosis with stenting 4 February 2016 II Chronic Kidney disease. 4 | CIRCUMSTANCES OF THE DEATH Margaret Wakefield was admitted to the Royal Cornwall Hospital, Treliske, Truro on 16 January 2016 with chest pain and end stage renal failure (3x time a week dialysis). She was diagnosed with severe ischaemic heart disease with coronary artery stenosis together with diabetes, high blood pressure, peripheral vascular disease and unstable mental health (Bipolar Disorder). On 4 February 2016 she underwent rotational atherectomy and Percutaneous Coronary Intervention and an intra-aortic balloon pump was used to maintain her blood pressure. The procedure was challenging due to the extent of the stenosis but despite the drill becoming stuck, this was rectified and she was stabilised and transferred back to the ward. She was due to have her dialysis.on the morning of 5 February, but she became unwell and unsuitable for haemodialysis. She instead required haemofiltration on the Critical Care Unit however there were no beds/staff available until 23:00 hours. Prior to a bed becoming available she developed chest pain and had a cardiac arrest. Despite resuscitation attempts she died that day as a consequence of her severe heart and renal disease. It was not clear whether to what extent the procedure or lack of availability of haemofiltration hastened her death. 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. — Margaret Wakefield suffered from unstable mental health which on occasions meant she had lack of insight into her medical needs. It was recognised by both the Cardiac Surgeon and Renal Consultant that she was very unwell, the procedure was high risk and that she would require dialysis and that Critical Care haemofiltration may be required. Mrs Wakefield deteriorated quickly and when a request for haemofiltration (which was necessary and potentially lifesaving) was made it was not available in a timely way. The lack of haemofiltration resulted in further deterioration and death occurred before the facility could be made available. The Consultant Surgeon and Renal Consultant both raised concerns as to the lack of haemofiltration for a patient with chronic renal disease following high risk heart procedure in a timely way, and the need for improved access to timely haemofiltration and contingency planning between the treating clinicians and Specialist critical care team. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. To review the clinical pathway of patients requiring regular haemodialysis when undertaking cardiac procedures and other surgery to ensure a smooth treatment pathway is in place prior to procedure to deal with renal complications should they arise. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 January 2017 (this allows for the festive period). 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 sel the Chief Coroner and to the following Interested Persons, | 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. [DATE] [SIGNED BY GORONER] 14 November 2016 Cueto Ut, Erarna MA
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.
One +all | we care Royal Cornwall Hospitals INHS| NHS Trust Chief Executive's Office Royal Cornwall Hospital 16 January 2017 Bedruthan House Truro Cornwall TR1 3LJ Tel: 01872 250000 Dr E E Garlyon PS Senior Coroner for Cornwall & Isles of Scilly Email: tf The New Lodge Newquay Road www.rcht.nhs.uk Penmount TRURO TR4 9AA Dear Dr Carlyon Re: Regulation 28 Report to prevent future deaths Margaret Erskin Hare Wakefield Thank you for your letter dated 14 November 2016 enclosing your Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Margaret Erskin Hare Wakefield which was heard on 3 October 2016. The matters you raised with the Trust were in regard to the need to access timely haemofiltration; contingency planning between the treating clinicians and the specialist critical care team; and the clinical pathway of patients requiring regular haemodialysis when undertaking cardiac procedures and other surgery: ensuring that a smooth treatment pathway to deal with renal complications should they arise, is in place prior to the procedure. In light of this death, the following actions have been put in place to improve the patient pathway and access to haemofiltration, which is carried out in the Crital Care Unit. e There has been an increase in the funded establishment for registered nurses in the Critical Care Unit: in February 2016 this increased to 11 nurses day and night and this was further increased to 12 since November 2016. At this time recruitment to the newly funded posts has not yet been completed but is underway. e The Critical Care Outreach Team, which reviews and advises on the care of patients on the wards, has been funded to increase the hours of operation from day time only to cover the full 24 hour period. The service will be fully operational 24 hours a day from 1 May 2017. My, ) Of : & spe ‘b, Interim Chairman: Dr Mairi McLean Chief Executive: Ms Kathy Byrne Care + Compassion | Inspiration + Innovation | Working Together | Pride + Achievement | Trust + Respect POS/y, fC e A new system has been introduced in which the Critical Care team reports patients awaiting discharge which is emailed to the Hospital Site Coordinators and Bed Managers. This ensures the same data is seen by the whole team at the same time and ensures that patient discharge from the Critical Care Unit is prioritised thus maximising capacity. This information is then reported and progress noted at the Site meetings which take place each day at 0800, 1200, 1600 and 1900. e The Critical Care Team is developing an Escalation Plan which will be operational from 1 May 2017. This will ensure standardisation and consistency of practice from the Trust when Critical Care Beds are not immediately available and again ensure that the Hospital Site Team is involved in maximising capacity in the Critical Care Unit. e The Trust has implementing a national programme known as SAFER. This is defined as; The ‘SAFER Patient Flow Bundle’: a set of interventions and clear parameters that, when delivered together as part of a multi-disciplinary approach help to ensure patients receive the right care, in the right place, at the right time, all of the time. This ensures efficiencies and reduced delays for patients, carers and relatives. Practical evidence of this is demonstrated by the development of daily meetings around the Swift Plus Board on each ward to clearly define all activity planned to take place to expedite patient discharge or treatment plans. e A new Patient Flow Policy was introduced in October 2016, to improve patient pathways for patients and ensure standards and a Clinical Director with responsibility for maximising patient flow throughout the system has been appointed. We believe that these changes strengthen the pathway of all patients requiring admission to the Critical Care Unit for delivery of their care and hope that this offers you the assurance you seek. Please do not hesitate to contact me should you require any further information. Yours sincerely Maw MCK Kathy Byrne Chief Executive se MOy, & O40 x e ¢ Wave “G, Interim Chairman: Dr Mairi McLean Chief Executive: Ms Kathy Byrne Care + Compassion | Inspiration + Innovation | Working Together | Pride + Achievement | Trust + Respect = ROS/y,
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.