Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0440, written 8 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2016 |
|---|---|
| Reference | 2016-0440 |
| Deceased | Mary Muldowney |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Mary Patricia MULDOWNEY (died 23.07.16)
THIS REPORT IS BEING SENT TO:
1. Professor Simon Mackenzie
Chief Executive
St George’s University Hospitals NHS Foundation Trust
Blackshaw Road
Tooting
London SW17 0QT
2. Dr Gillian Fairfield
Chief Executive
Brighton and Sussex University Hospitals NHS Trust
Eastern Road
Brighton BN2 5BE
3. Mr Nick Moberly
Chief Executive
King’s College Hospital
Denmark Hill
Brixton
London SE5 9RS
4. Mr Simon Stevens
Chief Executive
NHS England
PO Box 16738
Redditch B97 9PT
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
1
3
INVESTIGATION and INQUEST
On 26 July 2016 I commenced an investigation into the death of Mary
Muldowney, aged 57 years. The investigation concluded at the end of the
inquest earlier today. I made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Ms Muldowney’s medical cause of death was:
1a spontaneous subarachnoid haemorrhage (operated 20.07.16)
1b right posterior communicating artery rupture.
She was admitted to East Surrey Hospital at about 10am on Wednesday,
20 July 2016 and an intracranial bleed was immediately suspected. A CT
scan performed at 11.11am demonstrated subarachnoid and subdural
bleeds. Transfer to a specialist neurosurgical unit was sought as a matter
of urgency.
However, the transfer was refused by St George’s Hospital, Royal
Sussex Hospital, King’s College Hospital and others, on the basis that
they did not have an available intensive care bed.
In desperation, knowing of the neurosurgical expertise of a former
colleague, one of the East Surrey Hospital doctors went out of area and
rang a consultant neurosurgeon at the Royal London Hospital (RLH).
Invoking the universal acceptance policy [see Wells 1996], he accepted
transfer immediately, though in fact the RLH had no intensive care bed
available at that time.
Meanwhile, at about 1pm, Ms Muldowney woke up very briefly while
intubated and interacted with her daughter.
Ms Muldowney was at high risk of a re-bleed. The 2013 National
into Patient Outcome and Death (NCEPOD)
Confidential Enquiry
subarachnoid haemorrhage audit only recommended that sub arachnoid
haemorrhages be treated within 48 hours. However, I heard evidence
that this lady was obtunded, she was under anaesthetic, and her ruptured
aneurysm was complicated by a sub dural haemorrhage, so she needed
surgery immediately, regardless of whether there was an intensive care
bed currently available at the same hospital.
Ms Muldowney was transferred to the RLH and taken straight to theatre
at 4.40pm. Unfortunately, her pupils had become fixed and dilated in the
ambulance during transfer to the RLH and surgery did not save her. If
she had been transferred promptly, it probably would have.
2
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.
In the light of the gravity of Ms Muldowney’s situation, with the only
definitive treatment being surgery, she required immediate transfer to a
specialist neurosurgical unit, yet she was refused transfer by at least
three hospitals who said they had no intensive care beds.
She could have been transferred, undergone surgery, spent time in
recovery, and then an intensive care bed procured, perhaps even by
transferring out a non neurosurgical patient.
If such a bed was still unavailable, she could then have been transferred
to a different hospital, at least having undergone the time critical clot
evacuation and aneurysm clipping.
With prompt transfer and surgery, Ms Muldowney would probably have
survived.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 6 February 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
3
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Professor Dame Sally Davies, Chief Medical Officer for England
Mr Michael Wilson, Chief Executive of Surrey & Sussex Healthcare
Chief Medical Officer of Barts & The London
, consultant neurosurgeon, RLH
son & daughter of Mary Muldowney
I 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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
08.12.16
4
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