Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0109, written 7 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Apr 2017 |
|---|---|
| Reference | 2017-0109 |
| Deceased | Annette Krasinsky-Lloyd |
| Coroner | Darren Stewart |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Annette KRASINSKY-LLOYD
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
Ms Paula Head,
Chief Executive
Royal Surrey County Hospital NHS Foundation Trust
Egerton Road
Guilford
Surrey
GU2 7XX
1 CORONER
Mr Darren Stewart OBE, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
On 21st April 2016, an investigation was commenced into the death of
Annette KRASINSKY-LLOYD, an inquest was then opened on the 27th
April 2016 which concluded at the end of the inquest on 13th December
2016.
1
I found the medical cause of death to be:
1a. Hypovolemic Shock
1b. Retro-peritoneal Haemorrhage
1c. Pelvic Fracture II. Cerebral Infarction.
She died at Royal Surrey County Hospital on the 20th April 2016 as a
result of Hypovolemic Shock.
I concluded with the short-from conclusion: Accident.
4 CIRCUMSTANCES OF THE DEATH
Mrs KRASINSKY-LLOYD was a resident at Felbury House, Holmbury, St
Mary Dorking, Surrey. She had been resident there since July 2014
following a brief stay at Milford Rehabilitation Centre where she had
been admitted as a result of a fall at her home.
Over the period 18/19th April 2016 Mrs KRASINSKY-LLOYD suffered an
unwitnessed fall in her room at Felbury House which resulted in a
fracture to her pelvis causing a retro-peritoneal haemorrhage
(undiagnosed until 20th April 2016). She complained of groin pain on the
evening of 19th April 2016 which was monitored by staff at Felbury
House. Early on the morning of 20th April 2016 Mrs KRASINSKY-
LLOYD appeared much worse, suffering from pain in her legs and
stomach, slurred speech, she appeared yellow in colour, clammy to
touch, low blood pressure and was panting for breath. She was
transported by ambulance to the Royal Surrey County Hospital where
she was admitted to the Accident and Emergency (A&E) Department at
0745 hours on the 20th April 2016.
Following triage, Mrs KRASINSKY-LLOYD was moved to resuscitation
within the A&E Department. She was assessed at 0845 by an SHO (FY2)
who gained intravenous access and prescribed antibiotics and analgesia
(morphine). Fluids were also administered. The initial working
diagnosis was one of sepsis. Abdominal and chest x-rays were also
ordered. These were performed at 1000 hours and on review of the
imaging a consultant was called. Further investigation by the consultant
by way of a bedside ultrasound (performed around 1030 hours)
established a right-hand side mass in her abdomen. A CT scan was
requested which was conducted between 1100 – 1130 hours. Following
her return from the CT scan at 1130 hours, Mrs KRASINSKY-LLOYD’s
condition started to deteriorate with her blood pressure and heart rate
rising rapidly. She went into shock at 1147 hours with heart spikes and a
rapid fall in her blood pressure and a crash call was made. She was
2
stabilised and given a blood transfusion for the first time following
admission. The treating A&E clinicians were unaware that Mrs
KRASINSKY-LLOYD had been taking anti-coagulation therapy (low
molecular weight Heparin injections).
Mrs KRASINSKY-LLOYD’s condition deteriorated further and
assessment by surgeons resulted in a decision not to provide any invasive
treatment due to her co-morbidities. She was stabilised in A&E and
transferred to the care of the consultant on call for medicine. She was
first seen by the consultant on call for medicine at 1330 hours at which
point she appeared hypotensive, tachycardic, peripherally shutdown,
agitated and suffering from delirium. Her cannula had fissured. The
consultant on call for medicine addressed the poor intravenous access by
way of a femoral line. He reversed Mrs KRASINSKY-LLOYD’s anti-
coagulation therapy and ordered a further blood transfusion. He was
concerned with the deceased’s kidney failure, high lactate levels and
delirium.
The on call consultant for medicine’s assessment upon receiving Mrs
KRASINSKY-LLOYD into his care was one of a poor prognosis pointing
to the combination of low blood pressure, poor profusion to her vital
organs and acute renal failure, all of which had limited reversibility. Mrs
KRASINSKY-LLOYD’s condition further deteriorated during the
afternoon and she died at 1615 hours. The on call consultant for medicine
assessed that this was the likely outcome for Mrs KRASINSKY-LLOYD
irrespective of the course of treatment she received upon admission to
A&E on 20th April 2016 given size of the Retro-peritoneal Haemorrhage
and blood loss suffered by Mrs KRASINSKY-LLOYD.
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 could 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) It was clear from the evidence that the governance and rapidity of
treatment in A&E was inadequate. The SHO who initially
provided care to Mrs KRASINSKY-LLOYD was left un-supervised
for an extended period resulting in a delay of 90 minutes before
the relevant A&E consultant engaged in the care of the patient and
3
appropriate investigations undertaken to establish the nature of
the deceased’s condition.
(2) Notwithstanding (1) there were additional delays in obtaining
results of tests and the conduct of an appropriate assessment of the
deceased’s condition. This in turn led to delays in reversing the
deceased’s anti-coagulation therapy and administering blood
transfusions.
(3) At the time the on call consultant for medicine received Mrs
KRASINSKY-LLOYD into his care, she had further deteriorated,
including the fissuring of her cannula leading to poor intravenous
access. Between the end of the crash call at 1147 hours and when
Mrs KRASINSKY-LLOYD was transferred from the A&E
department (around 1330 hours), the monitoring of Mrs
KRASINSKY-LLOYD by the A&E department was inadequate
giving rise to the complication relating to poor intravenous access.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe you and your organisation 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 2nd June 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 this report to the following:
1. See names in paragraph 1 above
2.
3.
4. The Chief Coroner
In addition to this report, I am under a duty to send the Chief Coroner a
copy of your response.
4
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
7th April 2017 Darren Stewart OBE
5
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