Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0184, written 2 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Mar 2017 |
|---|---|
| Reference | 2017-0184 |
| Deceased | Paul Barber |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| 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.
VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the.City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPIFRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Brighton and Sussex University Hospitals NHS Trust HE Medico-legal Services Manager 2. Evelyn Barker, Chief Executive, Brighton and Sussex University Hospitals NHS Trust 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 12" August 2016 | commenced an investigation into the death of Paul William BARBER. The investigation concluded at the end of the inquest on 24" February 2017. The conclusion of the inquest was a Narrative Conclusion — please see attached Record of Inquest 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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 VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Samples being sent to microbiology in the wrong containers and to elaborate on that Mr Barber had a recently diagnosed aggressive lung cancer on the back of which he developed pericarditis. By the 21° July 2016 it was clear that there was a Collection of fluid around his heart which was susceptible to draining. This was done and sampling of the fluid was sent to the microbiologists for analysis. However, it was sent in the wrong container, this meant that it needed incubation before it could be dealt with giving a potential delay for results of between 24 — 48 hours. If it had been sent in the correct pot there is a good chance that full results would have been available the same day it was sent as the laboratory is open and testing until 7 p.m. (2) Delay in reporting important results to clinicians. On the 22" July bacterial growth was detected in the bottles and gram staining showed gram positive cocci — this information was passed to the medical team looking after Mr Barber. On the next day, Saturday 23% July, the laboratory found the sample growing two organisms. This indicated that Mr Barber had a bacterial pericarditis — this was a very unusual situation and the identification of the organisms ought to have been given on the Saturday as soon as it was known to the medical team. For some reason the organisms were not reported until Tuesday 26" July shortly after Mr Barber's death. Had these results been given appropriately on the 23% July appropriate steps could have been taken to treat the patient with antibiotics. It is right to say that in this particular case on the balance of probabilities the two failings mentioned above did not affect the outcome — however it is right to report this so that these mistakes are highlighted and do not occur again either in this Hospital Trust or any other. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND your organisation have the power to take such action. 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" May 2017 I, the coroner may extend the period. Your response must contain details of action taken or proposed to be taken, setting VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPILFRC. . GILVA D.J.TISSHAW, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 4. 2 3. Secretary of State for Health, Department of Health 4. Simon Stevens — Chief Executive NHS England | 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. 9 Date: 2°" March 2017 . SIGNED, 75 Senior Coroner Brighton and Hove a
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.
Brighton and Sussex Your ref: VHD/ST/INQ 13/17 (307/16) University Hospita Is 23 May 2017 The Royal Sussex County Hospital Eastern Road Brighton BN2 5BE Miss Veronica Hamilton-Deeley HM Senior Coroner Coroner's Office Woodvale Lewes Road BRIGHTON BN2 3QB Tel: 01273 696955 RECEIVED | 9 & WAY 2017 oe a ao ae a Em er see | Dear Miss Hamilton-Deeley The Late Paul Barber, date of birth: 09/02/1962 Thank you for your letter and report of 6 March 2017, and for drawing your concerns to the attention of this Trust. As you know, we are always willing to review our practices, to ensure we learn from experience. | was very sorry to learn about the circumstances of Mr Barber's death and the issues you have highlighted concerning the use of incorrect containers for microbiology samples, and a delay in reporting important results from the laboratory to ward-based clinical staff. | agree that, even though you had concluded these matters did not cause or contribute to the death of Mr Barber, it is still important to address them. In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascetic fluid, should only be submitted to the laboratory in a sterile white capped _Aontainer and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent / advising on the correct container to be used in such circumstances so that the staff learn from this. | note the initial blood culture result was notified to a doctor in the team caring for Mr Barber, who documented a plan about antibiotic treatment should the clinical situation warrant it. Mr Barber was reviewed each day by a consultant so that his condition could be closely monitored. Very unusually for any patient with bacterial pericarditis, sepsis was not a significant factor in Mr Barber's clinical condition. Concerning the delay in updating the clinicians caring for the patient about the new laboratory findings, the microbiology and infection department have discussed Mr Barber's case in detail at their clinical governance meeting, as part of training for microbiology registrars to help them discriminate effectively in prioritising urgent follow up for appropriate specimens. With our partner ey brighton and sussex S$ medical school Thank you once again for raising these concerns. Finally, please pass on my condolences to the family and friends of Mr Barber on their sad loss. Yours sincerely Dr George Findlay Executive Medical Director
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