Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0112, 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 | 2017-0112 |
| Deceased | Christina Witney |
| Coroner | Ian Singleton |
| Coroner area | Wiltshire and Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Great Western Hospitals 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.
Assistant Coroner for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Ms Nerissa Vaughan
Chief Executive
Great Western Hospitals NHS Foundation Trust
Great Western Hospital
Marlborough Road
Swindon
SN3 6BB
Patient Safety Domain
NHS England
Skipton House, Area 6C
80 London Road
London
SE1 6LH
CORONER
| am IAN SINGLETON, Assistant Coroner for Wiltshire and Swindon
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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/parl/7/made
INVESTIGATION and INQUEST
On 17 September 2015 an investigation was commenced into the death of Christina Bernadette Withey
aged 70. The investigation concluded at the end of the Inquest with a Jury on 31 March 2017, having
heard evidence on 28, 29, 30 and 31 March 2017. The conclusion of the Inquest was one of a narrative.
CIRCUMSTANCES OF THE DEATH
Christina was an inpatient at Great Western Hospital, having been admitted on the 10 September 2015,
with abdominal pain, constipation and pyrexia. At some point either late on the 14 September or during
the 15 September 2015 Christina suffered a stercoral perforation leading to faecal peritonitis, sepsis and
multi organ failure which caused her death on the afternoon of 15 September 2015.
CORONER’S CONCERNS
During the course of the inquest which was conducted with a Jury, evidence was heard from a number of
witnesses who had been involved with Mrs Withey’s care and or the subsequent investigation carried out
by the Hospital. It was accepted by the Hospital that in a number of respects the level of care provided to
Mrs Withey had not been as high as it might have been. Although the Jury found that those matters did
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
not contribute to her death they did give rise to a 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 keeping of patient records in relation to a urine chart and the accurate measuring of output.
(2) The period before a review of a patient is carried out where there has been no improvement in
condition.
(3) Review of the sepsis guidelines in the light of the “Acute care toolkit 9: sepsis” produced by The
Royal College of Physicians
(4) The training of locums and other temporary staff
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 02
June 2017. |, the Assistant 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 following Interested Persons :
DAC Beachcroft LLP
Portwall Place
Portwall Lane
Bristol
BS1 9HS
S J Edney Solicitors
Alexander House
19 Fleming Way
Swindon
SN1 2NG
| 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 Assistant Coroner, at the time of your response, about the release or the
publication of your response by the Chief Coroner.
Dated 07 April 2017 7 /)
Signature__ J“ )- g&
Assistant Coroner for Wy tshire and Swindon
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
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