Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0458, written 16 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 | 16 Dec 2016 |
|---|---|
| Reference | 2016-0458 |
| Deceased | Lita Serkes |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Lita SERKES (died 24.07.16)
THIS REPORT IS BEING SENT TO:
1.
Chief Medical Officer
Barts Health
Royal London Hospital
Whitechapel Road
London
E1 1BB
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.
3
INVESTIGATION and INQUEST
On 27 July 2016 I commenced an investigation into the death of Lita
Serkes, aged 80 years. The investigation concluded at the end of the
inquest earlier today.
I made a determination at inquest that Lita Serkes died from a
complication of a hysterectomy undertaken for endometrial cancer, being
a devastating bleed, the gravity of which was not immediately recognised.
I recorded a medical cause of death of:
1a
1b
intra abdominal haemorrhage
total abdominal hysterectomy and bilateral salpingo-oophorectomy
for endometrial adenocarcinoma, on 22.07.16
diabetes mellitus, hypertension, right cerebral infarct
2
1
4
CIRCUMSTANCES OF THE DEATH
The surgery performed at Whipps Cross Hospital on Friday, 22 July 2016,
was unremarkable. However, the following morning, Mrs Serkes suffered
a stroke and was transferred to the Royal London Hospital. By that
evening she was extremely unwell, and she died on Sunday, 24 July.
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.
1. The Whipps Cross medical notes record normal observations, most
specifically that Mrs Serkes was “alert” at 9.50am on Saturday, 23
July 2016. However, by that time, her son had been at her bedside
for nearly an hour and had himself realised that Mrs Serkes had
suffered a stroke. He saw no nurse conducting any observations at
this time.
Some five months on, no member of staff has yet addressed this
discrepancy with the nurse who recorded the observations.
2. When Mrs Serkes’
treating consultant gynaecological surgeon
attended her at 10.30am on Saturday, 23 July, he formed the
impression that he was the first person to diagnose the stroke.
In fact, her son and another doctor had already discussed the stroke,
and her son was under the impression that they were simply waiting
for an ambulance to transfer to the Royal London Hospital. (He was
already making arrangements to drive his father there.) None of this
is recorded in the medical notes.
3. The decision was made by, at the latest 10.30am, but quite possibly
an hour before then, to transfer Mrs Serkes to the Royal London
Hospital for specialist care, but transfer was not effected until 2.07pm.
Stroke is an emergency.
4. Patient controlled administration of pain relief was arranged for Mrs
Serkes, but she remained in pain. It was quite some time before it
was recognised that the device was not connected and so was not
delivering any analgesia.
2
5. Mrs Serkes’ surgeon went to the Royal London Hospital to see her at
10.30pm on Saturday, 23 July. He described in court palpating her
abdomen and there being no rigidity, guarding, or further distension.
However, he made no record in the medical notes of his attendance
and examination.
6. The same surgeon described in court his view that [static] imaging did
not disclose any active bleeding and so there was no indication to
return to theatre.
However, later in evidence he agreed that the scans simply showed a
collection of blood and could not demonstrate whether the bleeding
was active.
When I asked about the haemoglobin, he responded that at 3.04pm
that afternoon, it was recorded as 7 (he said 7, not 70), having
dropped from a normal level of 120. He explained that this result
might have been available earlier, but the computers were down in
the middle of the day.
After further discussion, the surgeon told me that, given the 8cm
haematoma he had diagnosed at the beginning of the day (Saturday,
23 July), he now believes that more efforts should have been made to
review the blood results earlier, and in any event before Mrs Serkes
was transferred to the Royal London Hospital.
He said that if he had considered the blood results earlier in the day,
he would have recognised a much bigger bleed than he actually
appreciated.
He said that he would probably have advised a further laparotomy –
though of course there is no way of knowing if Mrs Serkes would have
survived that.
7. The surgeon suggested that perhaps bloods should be taken routinely
at 6am so that they are available for the ward round, though he was
unsure whether the laboratory would be able to accommodate this.
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
3
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 13 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.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, obstetrician and gynaecologist
, husband and son of Lita Serkes
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
he believes may
interest. You may make
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
16.12.16
4
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.
Barts Health INHS| NHS Trust Chief Medical Officer Trust Executive Offices Coroner ME Hassell Pathology and Pharmacy Building Senior Coroner for Inner North London The Royal London Hospital St Pancras Coroner’s Court 80 Nesta pol Camley Street E12ES London N1C 4PP 6 February 2017 By special delivery Dear Ma’am, Inquest touching the death of Lita SERKES | write in response to a Regulation 28, Report to Prevent Future Deaths, dated 16 December 2016, which was made at the conclusion of the inquest into the death of Lita Serkes. Barts Health NHS Trust takes Coronial investigations very seriously and | am sorry you have had to make Preventing Future Death recommendations and | am grateful to you for highlighting your concerns. | note Lita Serkes died from a complication of a hysterectomy undertaken for endometrial cancer, that being a devastating bleed, the gravity of which was not immediately recognised. You have raised a number of concerns relating to the treatment received by Mrs Serkes. The seven concerns you have raised in the Preventing Future Death report are: 1. The discrepancy in the observation charts relating to Mrs Serkes being ‘alert’ has not been addressed with the member of staff who recorded them. 2. There was incomplete documentation in Mrs Serkes medical records. Mrs Serkes’ treating consultant believed that he was the first person to diagnose the stroke, however, Mrs Serkes son had already discussed this with another doctor. This conversation was not recorded in the medical records. 3. There was inadequate urgency in transferring Mrs Serkes to The Royal London Hospital on Saturday 23 July 2016. The decision was made to transfer Mrs Serkes at 10:30am but this was not effected until 02:07pm. 4. Mrs Serkes Patient Controlled Analgesia (PCA) system was not connected and this was not recognised for some time; leaving Mrs Serkes in pain. Barts Health NHS Trust: Newham General Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross Hospital. 5. Mrs Serkes surgeon described in court a physical examination that he carried out at The Royal London Hospital at 10:30pm on Saturday 23 July 2016 — the details of this were not documented in the medical records. 6. You felt that there was an inadequate urgency in chasing the blood results; if these had been reviewed earlier in the day the surgeon would have recognised that Mrs Serkes bleed was much bigger than he originally appreciated and he may have advised further surgery. 7. The surgeon suggested that routine bloods be taken routinely at 6am so that they are available for the ward round, though he was unsure whether the laboratory would be able to accommodate this. We have investigated the above concerns and | can confirm: 1. The requirement of making contemporaneous and accurate recording of patient observations has been reiterated to all nursing staff via the Safety Huddle. The discrepancy in this instance has been discussed with the nurse in question and they have been asked to reflect on this incident and have been given appropriate training. 2. All medical staff have been briefed on the requirement for complete and contemporaneous recording of all events in a patient’s medical records. 3. The Trust recognises that stroke is an emergency and that you feel there was inadequate urgency in managing Mrs Serkes stroke. As a result the Trust is currently in the process of reviewing the hospital policy for the management of stroke and is also reviewing the checklist of advice given by the Hyperacute Stroke Unit. The Trust is hoping that this will be completed by 01 April 2017. 4. To ensure that this doesn’t happen again, the pain team is giving on-going training to all nursing staff in the use of PCA machines. 5. It has been reiterated to the surgeon in question the importance and the requirement for complete and contemporaneous recording of all events in a patient’s medical records. He has also been instructed to reflect on this incident, to add it to his appraisal documentation and to discuss the incident at his next appraisal. 6. Again, the surgeon in question has been asked to reflect on this incident, to add to his appraisal documentation and to discuss at his next appraisal. 7. The Trust has reiterated to all medical staff the availability and option of using point of care tests when managing deteriorating patients. These are tests that can be carried out at the point of care ie. without having to send the sample to the laboratory. The Trust feels that by highlighting this option to all staff will ensure that investigations will be performed with the appropriate degree of urgency in the future. We can provide you with a copy of the SI report once it is completed upon request; this will highlight the areas that we as a Trust felt could be improved upon in future and the steps that we are taking to do so. | am once again grateful to you for bringing this case to my attention and | hope this letter fully answers the concerns you have raised. Yours faithfully Chief Medical Officer
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