Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0043, written 24 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Feb 2017 |
|---|---|
| Reference | 2017-0043 |
| Deceased | Doreen Stapleton |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Whittington Hospital NHS Trust |
| 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
Doreen Elma STAPLETON (died 15.09.16)
THIS REPORT IS BEING SENT TO:
1. Mr Simon Pleydell
Chief Executive
The Whittington Hospital NHS Trust
Magdala Avenue
London N19 5NF
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 29 September 2016, one of my assistant coroners, Richard Brittain, I
commenced an investigation into the death of Doreen Elma Stapleton,
aged 78 years. The investigation concluded at the end of the inquest on
yesterday. I made a narrative determination at inquest, which I attach to
this letter.
4
CIRCUMSTANCES OF THE DEATH
Doreen Stapleton died on 15 September 2016 at the Whittington Hospital
from a pulmonary thromboembolism.
5
CORONER’S CONCERNS
1
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.
Doreen Stapleton had been admitted to the Whittington Hospital
previously and diagnosed with pulmonary emboli. Upon discharge, ten
days before her death, a plan was made for district nurses to attend her
home daily, to administer tinzaparin injections. However, the referral was
never received by the district nursing team, because an obsolete email
address that had not been deleted from the computer system was used.
I am satisfied that Whittington Health has already taken steps to deal with
the cause of the failure of the district nursing team to attend – the
obsolete email address. I write in respect of an ancillary, but
nevertheless important matter, that of the instructions given to Ms
Stapleton and her family upon discharge.
During her six day admission, Ms Stapleton was told explicitly by one of
her treating consultants that without medication she could die, and she
did understand this. She was then persuaded to remain in hospital for
treatment. However, she later decided that perhaps she wanted to leave
after all, so on the afternoon of Friday, 2 September 2016, she was
detained under section 5(2) of the Mental Health Act.
By Monday morning, she was deemed fit for removal of the section, and
fit for discharge. It well may have been that her confusion on the Friday
had been a consequence more of her low oxygen saturations at that time,
than of her schizophrenia. Nevertheless, she was a vulnerable patient.
When she was discharged, although the plan of daily district nursing visits
was made clear to her, no member of the team had another very explicit
conversation with her or with her two sons, about the potential
consequence (i.e. death) of the visits and medication administration not
taking place. She and her sons were not given the telephone number of
the district nursing team and were not told to ring if nurses failed to attend
the following day. I understand that patients are now all given a leaflet
with the district nursing team telephone number, but I am concerned that
there is still a lack of emphasis on this aspect of discharge advice.
I heard from one witness that this is a whole team responsibility. Any
member of the team – consultant physician, consultant psychiatrist,
discharge nurse – could have had this very direct conversation with Ms
Stapleton and her family, but nobody did. I appreciate that there may be
a reluctance to be so blunt because of a fear of scaring patients, but any
reluctance must be overcome in certain situations if patients are to be
supported in the best way possible. Indeed, it had already been
overcome by one consultant earlier in Ms Stapleton’s admission.
2
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 24 April 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
, sons of Doreen Stapleton
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
24.02.17
3
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.
Dr Richard Jennings
Executive Medical Director
Whittington Health
Jenner Building
Magdala Avenue
London
N19 5NF
Email: r
t
Tel: 020 7288 5906
5th May 2017
]
Private and Confidential
HM Coroner Mary Hassell
HM Coroner’s Office
Sent via email only c/o
Our References: StEIS SI 2016.25397, Datix A40286, Whittington Hospital Number
893821
Dear Ms Hassell
Re: Regulation 28 Prevention of Future Deaths (PFD)
Thank you for your Regulation 28 Prevention of Future Deaths (PFD) report in relation of
Doreen Elma Stapleton sent to Mr Simon Pleydell, our CEO, on 24th February 2017. I am
replying on his behalf.
You originally asked us to reply by 24th April but your office kindly agreed to an extension
until today.
The actions we have taken in relation to your letter are as follows:
1)
and I, as Director of Nursing and Patient Experience and Executive
Medical Director respectively, will write to our doctors and senior nurses and
pharmacists to highlight what we think are the key learning points that arise out of
your concerns, so that they can consider how to embed these in their clinical
practice from now on.
2) I have raised the issues that you highlight in your letter at our Medical Committee on
16th March 2017 – this is a monthly meeting of the trust’s consultants and
management in which there are regular discussion around safety and learning, and
there was good discussion in this meeting about how consultants might take this
learning back to their teams.
3) On the specific issue of helping patients to understand the significance of pulmonary
emboli, we have reintroduced patient leaflets about pulmonary emboli on all of our
inpatient wards, and a spot audit to ensure that these are in place will take place
next week and again in one month’s time
4) I have asked our Associate Medical Director for Patient Safety,
, to
raise this issue on the Patient Safety Forum - this is a forum that is explicitly
focussed on safety and learning and is multidisciplinary, including pharmacists and
professions allied to medicine, as well as doctors and nurses.
Established as The Whittington Hospital NHS Trust
Chairman: Mr Steve Hitchins Chief Executive: Mr Simon Pleydell
5) I have asked our Chief Pharmacist to share this learning with all pharmacists on our
inpatient wards so that they can make an important contribution to ensuring that
patients understand the significance of their medication on discharge.
I have attached a copy of the letter that we are sending to our doctors and nurses and
wrote to
pharmacists, and I have also attached a copy of the letter that
at the CQC on 17th March. We are copying this letter to
also.
Please let me know if you feel that there is anything else that we should do to make
changes to embed the very important learning from this sad case.
Yours Sincerely
Dr Richard Jennings
Executive Medical Director
Enc.
1. Letter from
and pharmacists
and Richard Jennings to be sent to trust doctors, nurses
2. Letter from
to
, Hospital Inspection Manager
London, CQC dated and sent 17th March 2017
Cc:
, Associate Medical Director for Patient Safety, Whittington Health
, Director of Nursing and Patient Experience, Whittington Health
-
-
-
-
-
- Simon Pleydell, Chief Executive Officer, Whittington Health
-
Chief Operating Officer, Whittington Health
Hospital Inspection Manager London, CQC
Legal Services Manager, Whittington Health
Deputy Director of Strategy and Clinical Director for Clinical Support
Services, Whittington Health
Established as The Whittington Hospital NHS Trust
Chairman: Mr Steve Hitchins Chief Executive: Mr Simon Pleydell
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