Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0175, written 30 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 May 2017 |
|---|---|
| Reference | 2017-0175 |
| Deceased | Kenneth Evans |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 REPORT TO PREVENT FUTURE DEATHS
I Chef Executive, Dudley group of Hospitals NHS Trust
2 Chief Coroner
1
* CORONER
am Zafar Sdd que Senor Corone for the coroner area of the Black Country
2
CORONERS LEGAL POWERS
rr aks. ths report under paragraph 7 Schedule 5 of if e C roners and Justice
ct 2009
and regulabons 28 and 29 of the Coroners (Investgato s Regulatons 2013
3
INVESTIGATION and INQUEST
On the 16 MarcF 2017
Kenneth Evans The nvestgabon conc uded at the end of tFe nquest on
The conclus n
f the mquest was a arrat ye concl SlO
ommenced an mvesbgator
nto the death of the late Mr
0 May 2017
Mr Evans had a fal at home aid he fratured hs p ibc amus He was adrntted to
Russells Hall hosprta on the 27 February 2017 and r
rsk assessment for developwg
lots was u ide lake i He subsequent y developed a pu monary embolus and ded on
the 11 March 20 7
im for clots and also rissed
opportuntes to admnster hepann to mm mse the
sk of develop ng a pulmonary
embolus and these were gr ss fa ures n basc med cal are g v ng nse to neglect
Ihere was a falure to nsk asses
It e ca se of deatF vas
a Pulmora y Embo us
b rimobhty
c Mecanica
a
F THE DEATH
secondary Left Ventricular mpawment Ths s ar n- dcahon for thrombolyss
so he was given Alteplase at 17.00 and started on an IV Heparin infusion.
v) A further MET caM was put out at 17 45 as he had become pen-arrest (low
oxygen levels and hypotenson). He subsequently arrested (PEA rhythm)
requiring Advanced Life Support. The total hme without a cardiac output
was around 20 minutes before return of spontaneous circulation. He was
then admtted to the lntenstve Care Unit for or-going management
v; The next morning he needed ncreasing amounts of adrenaline and became
unstable The family had been fully informed of diagnosis. management and
his poor prognosis. After continued period of hypotension the decision was
taken to stop active treatments and focus on the patients comfort and
digmty Sadly he passed away on the 11 March 2017
5
CORONERS CONCERNS
During the course of the inquest the evidence revea{ed matters giving rise to concern, in
my opmion there is a risk that future deaths will occur unless action is taken In the
crcumstances it is my statutory duty to report to you
The MATTERS OF CONCERN are as follows.
1. Evidence emerged during the inquest that thromboprophyiaxs was not arranged
and no effective risk assessment of deveopmg blood clots was undertaken
6
AC11ON SHOULD BE TAKEN
Ir my op non action should be taken to prevent future dea hs and believe you have the
power to ake such action
You may wish to consde sett’ng up a revew of the. ool cy and training for the
relevant staff the reqLurements for th orr boprophy axs fo pahents who are
mmoble due to a history of fal s
a e
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fm ecort a 3fly’ oe;so
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°
30 May 2017
Mr Zafar Siddique
Senor Coroner
Black Country Area
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.
The Dudley Group Russells Hall Hospital Dudley West Midlands DY1 2HQ Reference reg28_KE_Julyl 7 Mr Zafar Siddique, HM Coroner Black Country Coroner’s Court Jack Judge House Halesowen Street Oldbury West Midlands B69 2AJ 21 July2017 Dear Mr Siddique, Regulation 28 report — Mr Kenneth Evans The circumstances of this failure to implement our existing policy were unusual in that the patient had been due for discharge from the acute service and because of a series of repeated delays in his discharge plans he was subsequently transferred to an intermediate care area of the hospital supervised by primary care physicians — Evergreen, and, therefore, had not been reassessed for VTE prophylaxis during this prolonged discharge journey. The Evergreen area is an intermediate care area where patients are admitted following discharge from the acute trust. These beds are utilised for patients who need nursing care but who are otherwise medically fit (analogous to nursing home patients). Following this incident we have made it clear to all staff that Evergreen is part of our services and thus subject to our Trust policy on VTE assessments. I have enclosed the Trusts policy for venous thromboprophylaxis (VTE) for your information as part of the Policy there is detail on how we monitor compliance with this Policy (contained within Appendix 1 of the Policy). Currently compliance in undertaking a VTE assessment for prophylaxis is at 93% for the Trust. All members of clinical staff are trained in the assessment of patients for VTE prophylaxis as part of their mandatory training. Awareness & the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending. On a further note due to the changing pattern & patient demand we are reconfiguring the Evergreen area to re-designate the beds as acute and these will be looked after by consultant medical staff. I hope that the above gives you confidence that whilst this failing was a result of a series of unusual events regarding Mr Evans discharge we have taken steps to remove any possible ambiguity in respect of undertaking a VTE assessment in accordance with our established and audited policy for all areas of the hospital. Yours faithfully D Wake Chief Executive Enc - Trust VTE policy Page I 2
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