Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0076, written 16 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 | 16 Mar 2017 |
|---|---|
| Reference | 2017-0076 |
| Deceased | Derek Turnbull |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Gateshead Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
Derek Winter DL Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Mr Ian D Renwick Chief Executive Gateshead Health NHS Foundation Trust Queen Elizabeth Hospital Sheriff Hill Gateshead NE9 6SX CORONER I am Derek Winter DL, Senior Coroner for the City of Sunderland 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 10" August 2016 Mr Derek Wynne Turn aged 86 years died at Sunderland Royal Hospital. I concluded the Inquest as part of my investigation on 15" March 2017 recording a conclusion of an Accident. The Cause of Death following Post-Mortem Examination was: - Ia Bilateral Bronchopneumonia; Contributed to by II Congestive Cardiac Failure; Ischaemic Heart Disease and Hypertensive Heart Disease; Right Subdural Haematoma consequent upon a fall CIRCUMSTANCES OF THE DEATH Mr Derek Wynne Turnbull had been a resident at the ICAR Unit since 1 August and he had a recognised risk of falls. He was on Warfarin. On 9" August 2016 Mr Turnbull was seen by a member of staff at 02:30am. Staff were alerted by an alarm in Mr Turnbull’s room that he was mobile at 03:15am and discovered him face down on the floor. His fall was not witnessed. Staff attended to Mr Turnbull’s facial injuries and, although he was observed, an ambulance was not requested to take him to hospital until 04:18am. Paramedics attended to Mr Turnbull at 04:35am and transported him to Sunderland Civic Centre, Burdon Road, Sunderland, SR2 7DN Tel 0191 5617843 | Fax 0191 5537803 | DX 60729 Sunderland www.sunderlandcoroner.co.uk Royal Hospital Emergency Department by 05:24am. Mr Turnbull had a CT Scan at 05:48am, and at 07:19am he was given Beriplex to reverse the effects of Warfarin. Mr Turnbull had a large acute-on-chronic subdural haemorrhage and surgical intervention was not an option. Mr Turnbull was made comfortable and passed away on 10th August 2016 at 08:15pm. 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: — Mr Derek Wynne Turnbull had a known history of falls, was on Warfarin and had sustained an obvious head injury after an unwitnessed fall, yet it took from 03:15am to 04:18am to summons an ambulance by a 999 call in a case that was to be “stepped up” to hospital in any event. There was no purpose in waiting, given the known scenario. In Mr Turnbull’s case the delay may not have caused or contributed to his death, but in other cases the opportunity for earlier review at the hospital ought to be taken. Policies, procedures and protocols may need to be reviewed in order to ensure that in those cases that are to be stepped up, that the action is taken immediately. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 15th May 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - e Family e Sunderland Royal Hospital e National Institute for Health and Care Excellence (NICE) e Care Quality Commission (CQC) e North East Ambulance Service and their Solicitors 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. Dated this 16™ day of March 2017 Signature Lhe. £) he, Senior Coroner for the City of Sunderland
John Adrian Gittins
Senior Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor,
Gwynedd LL57 2PW,
CORONER
lam Nicola Jones Assistant Coroner for North Wales (East and Central)
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 the 15th of February 2016 | commenced an investigation into the death of Catherine Haf
Roberts (DOB 26 May 1933 DOD 11 February 2016) The investigation concluded at the end
of the inquest on the 5th of February 2017. The conclusion of the inquest was one of Natural
Causes, the Cause of Death being recorded as 1(a) Acute Gastroenteritis
CIRCUMSTANCES OF THE DEATH
Mrs Roberts arrived at Ysbyty Glan Clwyd by ambulance at 01.26 hours on 6 February 2016
after becoming unwell at home with persistent diarrhoea. She waited in an ambulance outside
hospital until 03.25 hours due to the emergency department being full to capacity and Mrs
Roberts requiring a cubicle. As there was no space within the hospital on a medical ward Mrs
Roberts remained in the emergency department for 58 hours before being transferred to a
medical ward where her condition deteriorated. Mrs Roberts died in hospital on 11 February
2016.
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. —
The issues of admission to the Emergency Department/availability of resources/patient flow and
the multifactorial problems associated with cases of this nature have been reported upon by the
Senior Coroner on several occasions following previous inquests.
Despite the above reports issued to the Health Board these problems continue to the present
day and patients’ lives are being placed at risk as a result. Whilst | am aware that all necessary
parties are working towards a system plan to address these issues and that elements of that
plan have been agreed, there remains no agreed and effective system plan in place.
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.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LLIS LYN
Tel 01824 708047 | Fax 01824 708048
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
1 September 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 Family of the Deceased
lam 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
telease or the publication of your response by the Chief Coroner.
Dated 7 July
Signature |
Assistant Goroner{forlNorth Wales (East and Central)
7
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Tel 01824 708047 | Fax 01824 708048
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