Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0415, written 16 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 | 16 Nov 2016 |
|---|---|
| Reference | 2016-0415 |
| Deceased | Christopher MacMorland |
| Coroner | David Horsley |
| Coroner area | Portsmouth and South East Hampshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Portsmouth Hospitals University 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Portsmouth Hospitals NHS Trust Queen Alexandra Hospital Southwick Hill Road Cosham PO6 3LY 1 | CORONER | am David Clark Horsley, senior Coroner for the Coroner area of Portsmouth and South East Hampshire. 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 On 22" July 2016 | commenced an investigation into the death of Christopher Allen MacMORLAND (D.O.B. 13/10/1951). The investigation concluded at the end of the inquest on 1“ November 2016. The conclusion of the inquest was: Medical cause of death: - la: Multiple Organ Failure - |b: Sepsis - Ie: Spontaneous Bacterial Peritonitis and Pelvic Abscess - Il Myocarditis, Cardiac Hypertrophy, Chronic Obstructive Pulmonary Disease and Oesophagectomy for Carcinoma of the Oesophagus 2012. Coroner's Conclusion as to the death: Death due to Natural Causes. 4 | CIRCUMSTANCES OF THE DEATH Mr MacMorland was admitted to Queen Alexandra Hospital between 14" and 20" October 2015 having had difficulty feeding. A feeding tube was inserted and he returned home. He was readmitted to the hospital on 10'" November 2015 with abdominal pain and distension, feeling generally unwell. Despite treatment, his condition deteriorated and he died at the hospital on 5" December 2015. 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. — | was told in evidence at the Inquest that despite Mr MacMorland being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward - even though the consultants had during that time requested such a transfer on five separate occasions. Given the nature of his medical problems, from the evidence | heard, | am of the opinion that he could have benefitted from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome. | was also told that it is common for consultants’ requests for patient transfer to specialist wards not to be implemented. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation 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 11" January 2017. |, 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: - _Mr MacMorland's wife - onsultant Upper GI Surgeon | 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. 16” November 2016 David Clark Horsley
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.
Portsmouth Hospitals INHS| NHS Trust Fs Trust Headquarters r . F Level, Queen Alexandra Hospital Interim Chief Executive Southwick Hill Road Cosham PORTSMOUTH, PO6 3LY Tel: 023 9228 6877 Mr D C Horsley HM Coroner for Portsmouth and South East Hampshire The Coroner’s Court 1 Guildhall Square Portsmouth PO1 2GJ 20 December 2016 Our Ref: TP/JH/Q163/15 Dear Mr Horsley Regulation 28 letter Re: Christopher MacMorland DOB 13.10.51 Inquest date: 1 November 2016 The Regulation 28 letter refers to the care of this patient which was provided by both an Upper Gastrointestinal (UGI) Surgeon and a Gastroenterologist. Your concerns related to the failure to transfer the patient to a Gastroenterology ward as requested by the Gastroenterologist. The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon. The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised. By way of further assurance, since this death in 2015, the Hospital has begun a ‘buddy’ ward system whereby patients of a certain specialty are cohorted only into the appropriate specialist ward or a specific buddy ward. This means that consultants will have their patients only on one other ward if their own base ward is full. | trust this provides you with appropriate reassurance. \ Yours sincer Tim Powell Chief Executive
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