Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0139, written 18 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 | 18 Apr 2017 |
|---|---|
| Reference | 2017-0139 |
| Deceased | David Birtwistle |
| Coroner | Terence Moore |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Bristol NHS 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. University Hospitals Bristol NHS Trust 2. Brisdoc 3. NHS 4 CORONER | am Terence G. Moore, Assistant Coroner, for the Area of Avon. 2 | 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. 3 | INVESTIGATION and INQUEST On 30" November 2016 an investigation commenced into the death of David Lee BIRTWISTLE, Aged 44. The investigation concluded at the end of the inquest on 23 March 2017. The conclusion was that the medical cause of death was \(a) Pulmonary embolism; I(b) Deep vein thrombosis and cardiomyopathy The.conclusion as to the death was a narrative conclusion which read: Mr. Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death. This meant that further tests, which could have led to an earlier diagnosis of his condition, were not done. 4 | CIRCUMSTANCES OF THE DEATH Mr. Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death. This meant that further tests, which could have led to an earlier diagnosis of his condition, were not done. No 111 referral information was available to “front door” or the ED. 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. . The MATTERS OF CONCERN are as follows. — 1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements. 2. Any future “front door” project should consider the recommendations of the recent RCEM report “Initial Assessment of ED patients” 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the. i I I " | i I iq 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 14" June. |, 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 following Interested Persons — the family. | 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. 18" April 2017 Mr. T. G. Mo a_i
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. NHS
1 | CORONER
| am Terence G. Moore, Assistant Coroner, for the area of Avon.
2 | 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.
3 | INVESTIGATION and INQUEST
On 30" November 2016 an investigation commenced into the death of David Lee
BIRTWISTLE, Aged 44. The investigation concluded at the end of the inquest on 23%
March 2017.
The conclusion was that the medical cause of death was
I(a) Pulmonary embolism; I{b) Deep vein thrombosis and cardiomyopathy
The conclusion as to the death was a narrative conclusion which read:
Mr. Birtwistle died of a pulmonary embolism having been diverted from an
accident and emergency assessment two days prior to his death. This meant that
further tests, which could have led to an earlier diagnosis of his condition, were
not done.
4 | CIRCUMSTANCES OF THE DEATH
Mr. Birtwistle died of a pulmonary embolism having been diverted from an
accident and emergency assessment two days prior to his death. This meant that
further tests, which could have led to an earlier diagnosis of his condition, were
not done.
No 111 referral information was available to “front door” or the ED.
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.
The MATTERS OF CONCERN are as follows. -
4. Anational review of serious incidents and near misses in similar “front door”
services should happen as a matter of some urgency in order to identify
common themes that can inform future service design.
2. NHS 1114 should share information with ED departments immediately. This
needs to be in a user friendly format.
6 | 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 14" June 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 following Interested
Persons — the family, University Hospitals Bristol NHS Trust and Brisdoc.
| 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 bythe Qhief Coroner.
18” April 2017 T. G, Moore :
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