Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0176, 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 | 2017-0176 |
| Deceased | Sarah Poole |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Royal Wolverhampton NHS Trust. 2. Chief Coroner 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 2 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. 3 INVESTIGATION and INQUEST On the 4 April 2017, I commenced an investigation into the death of the late Mrs Sarah Poole. The investigation concluded at the end of the inquest on 16 May 2017. The conclusion of the inquest was a narrative conclusion: Natural causes contributed to by neglect. The cause of death was: 1a Cardiac Dysrhythmia (Ventricular Fibrillation) b Cerebral Anoxia/Brain Injury c Acute Aortic Dissection with Aortic Rupture and Cardiac Tamponade (Operated 29/10/2016) ll Hypertension 4 CIRCUMSTANCES OF THE DEATH i) Ms Poole was admitted to New Cross hospital after complaining of sudden onset of headache and back pain on the 28 October 2016 shortly after 11pm. ii) An ECG performed by ambulance staff was abnormal. She was then triaged by nursing staff and assessed at Level 4 before being given pain relief medication. iii) She was seen by a doctor at 1:50am who recorded a history of anxiety and panic attacks, headaches and pain in her back and chest. Her observations were normal and it was incorrectly concluded that her ECG was normal when the wrong ECG was examined relating to another patient. iv) She was later discharged home and no discharge papers were given to the family. v) Her condition continued to decline and she was readmitted back to hospital on the 29 October at around 1pm; a scan and further investigation revealed an aortic dissection. vi) She then had emergency surgery which was a complex operation with 1 [IL1: PROTECT] associated risks. vii) She developed further complications post operatively and by the 3 November a CT brain scan revealed minimal brain activity. She sadly passed away on the 5 November 2016. 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. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff. 6 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. 1. I understand that since this incident a number of measures have been introduced including reinforcing the requirement to sign all ECG’s. However, a recent audit (May 2017) indicated that out of twenty cases examined there were still two failures by the clinician to endorse the ECG. 2. You may wish to consider setting up a review of the policy and training for the relevant staff concerned and a consideration of an escalation policy for those who continue to fail to adhere to policy and instructions. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 July 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 my report to the Chief Coroner and to the following Interested Persons; Family. 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 30 May 2017 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT] 3 [IL1: PROTECT]
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 Royal Wolverhampton INHS| NHS Trust JO/LNR New Cross Hospital Wolverhampton Road Wolverhampton West Midlands WV10 0QP. Tel: 01902 307999 Private and Confidential For the attention of Mr Z Siddique HM Senior Coroner Black Country Coroner’s Court Jack Judge House Halesowen Street Oldbury B69 2AJ 19 July 2017 Dear Mr Siddique RE: PATIENT SARAH POOLE - DECEASED - HOSPITAL NUMBER H19006_ DOB 01/03/1978 ee OE SE EE NEED IU VB VEY NIL Firstly, please may | express my condolences on the death of Sarah Poole. | write this letter in response to the regulation 28 report to Prevent Future Deaths dated 30" May 2017. The concerns raised at the inquest on the 4" April 2017 relate to Miss Sarah Poole, and are that there were failures to record and endorse the name of the Doctor reviewing the ECG and the failure to take into account previous abnormal ECG results. The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker, i.e. a middle grade Doctor or Consultant. This policy will be audited on a monthly basis with 20 sets of ECGs being reviewed to ensure that each ECG has been signed off by a Senior Decision Maker and also to audit whether documentation relating to the ECGs is being made in the patients notes. We have just completed the audit for June 2017 and this shows a 100% compliance with a Senior Decision Maker signing and reviewing the ECG, and 90% compliance with documentation being made in the notes. Where there have been omissions the individuals concerned are identified and advised of the requirement to comply with the measures. However, if they persist in not complying then the Trust will instigate misconduct proceedings. Chairman: Chief Executive: David Loughton CBE Preventing Infection - Protecting Patients A Teaching Trust of the University of Birmingham Safe & Effective | Kind & Caring | Exceeding Expectation eS Mi 2382414 12.10.16 The department has also developed an algorithm for how to manage an abnormal ECG, which has been approved by the Consultant Body and will be taken to the departmental Governance Meeting for ratification and will be in place for the next Junior Induction in August 2017. This process will be reinforced during a “Focus Fortnight” for Nurses during July 2017. Also, the message will be delivered using the Departmental Safety Briefings twice daily as a way of reinforcing the new process. This will also be backed up by posters describing the new process. With regards to the ambulance handover there have been problems with the new electronic handover system producing lengthy documents. However, we have now introduced a way of summarising this information into 1 to 2 sheets which will be printed off and attached to the ED patient documentation. To ensure that medical staff review this information we have included in the discharge checklist (shared at the inquest) a statement which will ask the clinician to confirm that they have read the pre-hospital information. The checklist has been agreed by the Senior Team in ED and is in the process of being incorporated electronically into the printed element of ED patient documentation. We cannot confirm at this time the exact implementation date but it will be within the next month, and along with the ECG process we plan to audit the compliance with the discharge checklist on a monthly basis. Please let me know if you require any additional information. Yours sincerely Dr Jonathan Odum MEDICAL DIRECTOR
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