Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0421, written 24 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 | 24 Nov 2016 |
|---|---|
| Reference | 2016-0421 |
| Deceased | Timothy Jones |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Community health care and emergency services 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 THIS REPORT IS BEING SENT TO: 1.Richmond Medical Centre 2. Clinical Commissioning Group CORONER 1 am Louise Hunt Senior Coroner for Birmingham and Solihull, 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. INVESTIGATION and INQUEST On 27 July 2016, | commenced an investigation into the death of Timothy Simon Jones. The investigation concluded at the end of an inquest on 24th November 2016. The conclusion of the inquest was due to natural causes. CIRCUMSTANCES OF THE DEATH The deceased was known to suffer from Downs Syndrome, Epilepsy and Dementia. He required PEG feeding. He had frequent admissions to hospital with chest problems in the year before his death. He was admitted to Solihull Hospital on 13 July 2016 with difficulty breathing. He was treated for aspiration pneumonia and a DNAR order was put in place. He was discharged on 15 July 2016 at 17.00. He was readmitted at 22.43 the same day with a decreased level of consciousness and breathlessness thought to be due to further aspiration or hospital acquired pneumonia. He deteriorated and died on 17 July 2016 at 05.55. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: a, PNEUMONIA 2. DOWNS SYNDROME. PEG FEEDING, DEMENTIA AND EPILEPSY 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. Ihave concerns about record keeping at the practice. The residential home records recorded that the GP had visited the patient on 25 May 2016, however the GP could not find a record of that visit in the electronic notes. It is vital the accurate records are kept of contact with patients and clinical decisions made. 2. theard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. 3. There was no clinical assessment of the deceased by a GP after the 25 May 2016 despite his deteriorating condition and complex needs. 4. The GP’s policy for home visits (copy attached) did not contain any reference to those with complex chronic conditions who were residents in care or residential facilities. The policy actively seeks to avoid home visits which may have influenced decision making in this case. 5. The deceased was diagnosed with aspiration pneumonia when he was admitted to hospital. He was at high risk of aspiration pneumonia. | heard evidence that the best antibiotics for aspiration pneumonia are co-amoxiclav. The deceased was not prescribed these in the community he was given amoxicillin instead. Consideration needs to be given whether guidelines should be produced to clarify which antibiotics are required in specific situations. 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 27 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: The family cac NHS England 1am 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. 24 November 2016 J \ f Signature. Louise Hunt Senior Coroner Birmingham and Solihull
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.
Friars Gate
1011 Stratford Road
Shirley
Solihull
West Midlands
B90 4BN
General number: 0121 713 8399
Direct line number:
www.solihullccg.nhs.uk
PRIVATE & CONFIDENTIAL
Mrs L Hunt
HM Senior Coroner
Birmingham & Solihull Areas
Coroner’s Court
50 Newton Street
Birmingham
B4 6NE
Your ref:
26th January 2016
Dear Mrs Hunt
Your reference :
RE: Timothy Simon Jones (deceased)
Thank you for forwarding the Report to Prevent Future Deaths issued following the inquest
of the above named individual.
I have read and considered the matters of concern outlined and propose the following
actions.
A communication will be sent to all Solihull member practices via the CCG
communication mode ‘little and often’ to highlight the issues raised in the Regulation
28 report;
In addition a ‘learning alert will be issued to all Solihull member practices to highlight
concerns and learning in relation to:
o
o
o
o
The CCG will ask the Local Medical Committee to discuss with its members the
consideration of a Solihull wide home visiting policy;
Advice will be issued to practices in respect of record keeping;
Recording of requests for home visits
GP home visit policies
Nursing/residential home requests for GP home visits
Classifications of administrative tasks
Page 1 of 2
Key points from the case will be used to build service requirements for review of GP
support to care homes
The Birmingham and Solihull Area Prescribing Committee has approved local antimicrobial
guidelines which are promoted to practices. These guidelines are based on the PHE
guidance for the management of common infections in Primary Care and are adapted for
local use by the Birmingham and Area Antimicrobial Group (BAAG) which has representation
from primary and secondary care across Birmingham. Neither the PHE guidelines nor the
local version include a recommendation for aspiration pneumonia. The recommended
antimicrobial therapy for community acquired pneumonia for adults is amoxicillin. In
addition to the actions above we are asking the BAAG via our local microbiologist to
consider the inclusion of aspiration pneumonia within the local version of the Primary Care
Guidelines.
I do hope that the actions described in this letter provide you with the assurance that we
have taken this matter seriously. We shall implement these actions to the timelines given in
the attached action plan.
Yours sincerely
Chair and Clinical Lead
Page 2 of 2
See every Prevention of Future Deaths report matching Community health care and emergency services 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.