Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0182, written 6 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jun 2017 |
|---|---|
| Reference | 2017-0182 |
| Deceased | Joyce Rumming |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
DAVID W. G. RIDLEY Senior 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 1 CORONER |! am DAVID RIDLEY, Senior Coroner for Wiltshire and Swindon 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION On 14/12/2016 | commenced an investigation into the death of Joyce Violet Rumming who was born on 2 September 1931. Violet died at The Great Western Hospital in Swindon on 12" December 2016. The Investigation was commenced as information was supplied in order to make the decision that a post mortem was required that whilst at The Great Western Hospital Joyce may have been given antibiotics in respect of which she was allergic to. | was informed that there had been a previous occasion that resulted in a reaction. As such the investigation post mortem itself was carried out at Salisbury District Hospital because of the possible conflict of interest. 4 CIRCUMSTANCES OF THE DEATH Joyce had arrived at the Accident and Emergency Department of The Great Western Hospital late on the 11 December 2016, she was alert and orientated and appeared to respond clearly to questioning. She had previously been diagnosed with a chest infection in respect of which she had recently completed a course of antibiotics. The Ambulance Acute Referral Form identified that Joyce was allergic to Amoxicillin but it does not appear that this was conveyed to those in the Emergency Department room at handover. The allergy does not appear to have been picked up by the Emergency Department room staff when considering the Ambulance Acute Care Referral Form. Shortly before midnight one of the nurses in consultation with the patient’s son and husband present documented an allergy to Amoxicillin on the reverse of the Care Plan. Joyce, to confuse matters had also stated to another nurse when asked that she had no allergies although there appears to have been a concern that she may have been concerned. A Doctor having checked the internal Medway System and a ED CAS card went on to prescribe Amoxicillin in respect of which Joyce apparently had an allergy following a previous reaction. It would appear that the allergy following a previous admission was recorded on the EPMA System (not used in the ED) and not on Medway which is accessible in the ED. It would appear that on the previous admission that the allergy had also been documented on the drugs chart. The Amoxicillin and Clarithromycin were administered at 01.45 on the 12" December 2016 and sadly Joyce passed away just over % hour later. Having made further enquiries the cause of death | Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 highlighted that Joyce’s death was due to respiratory failure but that it did not appear to be related to an allergic reaction to the Amoxicillin. It will shortly be the case that the investigation will be discontinued on the basis that the cause of death appears to be natural and — suggests the following as a cause of death which | have no reason to reject:- 1a) Type Il respiratory failure and respiratory acidosis 1b) Large sliding hiatus hernia 2) Chronic asthma, recent lower respiratory tract infection and coronary artery atherosclerosis. CORONER’S CONCERNS Helpfully a Route Cause Analysis was undertaken which highlighted as a care service delivery problem the fact that an antibiotic, Amoxicillin, in respect of which it was believed that Joyce was allergic to following a previous allergic reaction had been given to her shortly before her death. The Route Cause Analysis in relation to items (bullet points) under contributory factors documents a number of areas that give rise for concern. It essentially amounts to right hand not communicating with the left hand in that for example unless a Doctor looks in a specific location due to issues as regards the communication between various software packages that the existence of an allergic marker could easily be missed as was the situation in relation to Joyce’s case. A number of recommendations have been highlighted which have been documented at items 1-4 in the action plan. | share the concerns highlighted by the Route Cause Analysis and the purpose of this Regulation 28 Report is to enable a mechanism whereby your Trust feeds back both to myself and to the family the results of the recommendations and provides details in respect of what changes will be made and if changes cannot be made as to why they cannot be made. Proceeding in this way will allow the family to secure a full death certificate following discontinuance which will take place a few days after this Regulation 28 Report is sent out. | have attached for ease of reference Appendix A which contains the 4 recommendations. 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 normally under a duty to respond to this report within 56 days of the date of this report, namely by the 1" August 2017. | am however aware that the due date in relation to dealing with all the points is in the future and therefore | have extended the period for response until Friday the 15" September 2017. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons | have also sent it to Director of Commissioning (South Central) NHS England Bewley House Marshfield Road Chippenham Wiltshire SN15 1JW Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 who may find it useful or of interest. lam 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. Dated 06 June 2017 No) DN a Signature Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
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.
Great Western Hospitals [i'/i FJ Private and confidential The Great Western Hospital Mr David Ridley Marlborough Road Senior Coroner for Wiltshire and Swindon Swindon SN3 6BB Wiltshire and Swindon Coroner's Office 26 Endless Street Tel: 01793 60 40 20 Salisbury Wiltshire SP1 1DP 11 September 2017 Dear Mr Ridley Re: Regulation 28 Report to prevent future deaths Joyce Violet Rumming (deceased) Thank you for your letter addressed to PF dated 6 June 2017 where you had detailed recommendations for the Trust. This letter sets out the Trust’s response to your report. The Trust takes patient safety seriously and has clinical risk processes in place to investigate cases where a patient had or could have suffered harm and to identify areas of potential learning. In your letter you opined that you had shared the same concerns which were identified in the Trust’s own investigation (Root Cause Analysis). In this letter | will endeavour to set out a summary of the progress the Trust has made with the recommended actions in the Trust's own investigation. Action One — Handover process between the ambulance service and the Trust In October 2016, the ambulance service changed from a handwritten record detailing patient care to an electronic system. With all new documentation it takes time to embed, the Emergency Department staff are now familiar with the new ambulance documentation. The Clinical Risk team had liaised with the local ambulance trust to see whether any changes can be made to the electronic system so that key information, such as allergies, is at the top of the handover document. Our local ambulance trust works with many acute hospitals in the South West region. We have been advised that it is not possible to make Our Values Service Teamwork Ambition this change as the electronic system cannot be tailored for each individual organisation which the ambulation trust works with. There is a future plan to introduce a joint IT system between ambulance trusts and hospitals and we understand that a pilot is scheduled in the next couple of years. Action Two — Review of documentation of allergies The majority of documentation in the Emergency Department is electronic. On the electronic patient record system there is an alert section where drug allergies are to be noted. The alert notification tab is then flagged red on the patient’s home page. The Emergency Department continuously review their documentation and there are future plans to implement a new clinical note. The clinical note is an electronic record with specific questions for the clinician to answer when assessing the patient. The new clinical note is planned to include patient allergies. Action Three — Explore the interface between IT systems The IT infrastructure did not and still does not support sharing of information between the electronic patient medication system and the electronic patient record system. Actions two and four are to bridge this gap and ensure patient safety. The Trust plans to explore the IT infrastructure further in the future relating to the interface between the two systems. In addition to this the Emergency Department are being migrated onto the same server which the rest of the Trust uses. This will make it easier for Emergency Department staff to have access to the electronic patient medication record to look up any allergies and with the potential to prescribe medication using this system. Action Four — Review the allergy alert system / process / policy The Medications Safety Group has developed six factsheets relating to patient medication allergies. The factsheets are available to all staff and are located on the Trust intranet. The factsheets cover the assessment of an allergy, how to document and share this information and how to treat the patient. The six factsheets are included with this letter for your information. The policy is currently being drafted however in the interim the factsheets provide adequate guidance on allergies. | hope that this provides you with assurance that the Trust has put measures into place to improve systems around patient allergies. Our Values Service Teamwork Ambition § If you require any further information please do not hesitate to contact me. Deputy Chief Executive and Medical Director encs Our Values Service Teamwork Ambition Respect
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