Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0035, written 2 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Mar 2017 |
|---|---|
| Reference | 2017-0035 |
| Deceased | Terence Millington |
| Coroner | Christopher Dorries |
| Coroner area | South Yorkshire (West) |
| 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: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Sheffield Teaching Hospitals Trust
1
CORONER
Christopher Peter Dorries, senior coroner for South Yorkshire (West)
2
CORONER’S LEGAL POWERS
I 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
4
INVESTIGATION and INQUEST
On 23rd November 2015 I commenced an investigation into the death of Terence
Millington (aged 82). The investigation concluded at the end of the inquest on 7th
November 2016. The (narrative) conclusion of the inquest was that:
Mr Terence Millington died at Weston Park Hospital Sheffield on the 18th November
2015, primarily in consequence of his severe lung disease although this was not
expected to take his life at that moment. His persistent epistaxis through the early
morning of 18th November was the trigger for the physiological failure that led to his
death and as such was a significant cause of death whilst not leading to exsanguination.
CIRCUMSTANCES OF THE DEATH
Mr Millington was admitted to Weston Park Hospital on 12th November 2015 with severe
back pain related to metastatic cancer. He also suffered from significant pre-existing
respiratory disease.
Early on 18th November Mr Millington suffered a nose bleed which was dealt with.
Unfortunately he then suffered a second bleed which was again dealt with although with
more difficulty. However a subsequent (third) bleed proved more intractable and Mr
Millington suffered a cardiac arrest. As noted in the narrative conclusion (see above) the
persistent epistaxis was found to be the trigger for the physiological failure leading to
death.
The doctor who had attended Mr Millington during that night was an SHO with some
(albeit limited) ENT experience. He had previously placed an anterior nasal pack but
never a posterior pack. As the situation progressed this doctor made efforts to escalate
Mr Millington’s care to the ENT SpR on call without success. A Trust investigation was
told that the doctor slept through the ring tone of her mobile phone despite repeated
calls.
The SHO then made contact (without difficulty) with the on-call consultant who gave
telephone advice. This doctor told the court that he lived in Retford. At the time of the
final bleed there was further discussion between SHO and consultant at which time the
junior doctor wanted physical assistance -- but in fairness Mr Millington deteriorated and
arrested so quickly that even a doctor resident in the hospital complex may not have
1
reached him in time.
The inquest also noted that whilst one of the two packs requested by the SHO arrived
from the Royal Hallamshire site, the other one was wrong and thus could not be used.
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.
It is acknowledged that an incident investigation was undertaken by the Trust at my
invitation during the inquest which sets out steps to be taken to prevent a repetition of
the contact issue. Nonetheless I believe this report remains necessary so that lessons
might be learnt beyond the Sheffield Teaching Hospitals Trust.
The MATTERS OF CONCERN are as follows: –
That an on-call senior doctor (the SpR) did not make satisfactory arrangements
to ensure that she would waken if telephoned.
That the next on-call (the consultant) would have had no opportunity to attend
promptly because of the distance from his home. The AA website shows that
from the centre of Retford to Weston Park would take over 50 minutes although
it is accepted that the consultant may live on the Sheffield side of Retford. For
clarity, it is acknowledged that the consultant would not have had time to attend
in this case (from when the request was actually made) even if living much
closer.
That the request for two packs was not met correctly.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 27th April 2017. I may extend this period upon request.
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. Again
the Investigation Report is noted and your reply will no doubt make reference to this
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to Mr Millington’s family. I have
also sent a copy to the Care Quality Commission who may wish to disseminate the
issues further.
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 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.
9
2nd March 2017 CP Dorries
2
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.
Sheffield Teaching Hospitals NHS} NHS Foundation Trust Chief Executive’s Office 8 Beech Hill Road SHEFFIELD $10 2SB Tel: 0114 2712436 Our ref: AJC/SB/PFDTM 27 April 2017 Mr C P Dorries HM Senior Coroner Medico-Legal Centre Watery Street Sheffield $3 7ES Dear Mr Dorries Re: Response to Regulation 28 - Report to Prevent Future Deaths | write further to your report dated 2 March 2017, following the inquest into the death of Terence Millington. | would firstly like to offer our condolences to Mr Millington’s family along with our sincere regrets for the distressing circumstances surrounding his death. We take very seriously the findings of the report, which we have considered carefully. Our response to the specific Matters of Concern within the report is outlined below: 1. In relation to the fact that the on-call senior doctor (the SpR) did not answer the calls to her telephone, the consultant has discussed the incident with the doctor concerned. She was unable to offer any reason why the calls failed to wake her, other than she was very tired and in a deep sleep. She is sincerely sorry and has reflected on and learnt from the incident. From 1 April 2017 the local induction within ENT has included reference to the responsibility of non-resident on-call medical staff to remain contactable and, over the coming months, this is also to be incorporated within the central induction programme for medical staff. In addition, we are in the process of reviewing and amending the Trust’s requirements for staff who are on call from home to ensure that both a primary and an alternative contact number are registered with switchboard. We expect this to be completed by the end of July 2017. In relation to the issue of contacting medical staff overnight and at weekends, it is important to note that increasing numbers of junior doctors, particularly in the more acute specialties, work resident shifts out of hours rather than being on-call from home. For these doctors, problems relating to contact are not a concern as they remain on site and in the relevant clinical area throughout the out of hours duty period. _ 4 e res egnte f- mia Sheffield Tt Hospitals in hospital and in the community * Charity proud to make a difference Chair: Tony Pedder OBE Chief Executive: Sir Andrew Cash OBE 2. Regarding the issue of the next on-call doctor (the consultant) and the distance from his home j in investigation of the case of this specific consultant is being undertaken by || ee Trust's Medical Director. The requirement is for on-call medical staff to be able to attend the hospital within 30 minutes and, whilst there are a number of consultants who live more than 30 minutes away from the hospital, they are required to make arrangements to Stay locally at a location which meets the ‘30-minute requirement’ when on call. 3. In response to the issue of the availability of the two nasal packs, an emergency epistaxis bag for on-call medical staff who are required to attend patients elsewhere in the Trust is now available on ward I1 at the Royal Hallamshire Hospital. The availability and the contents of the bag have been incorporated within the monthly heaith and safety checklist so that this will be regularly monitored. In order to ensure wider learning, the incident and the actions outlined above are to be presented at the Trust’s Safety and Risk Management Board meeting on 24 May 2017. Finally, | hope that the above comments address the Matters of Concern within your report and | would be happy to answer any outstanding queries. Yours sincerely Rroveu J. Cosh, Sir Andrew Cash OBE Chief Executive
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