Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0190, written 15 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 | 15 Jun 2017 |
|---|---|
| Reference | 2017-0190 |
| Deceased | Kevin Mann |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Matthew Hopkins, Chief Executive, Barking, Havering & Redbridge University Hospitals NHS Trust. Executive Offices, Queens Hospital, Rom Valley Way, Romford, Essex, RM7 0AG. 1 | CORONER | am Nadia Persaud, Senior Coroner for the Coroner Area of East London 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/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On the 14" September 2016 an investigation commenced into the death of Mr Kevin George Mann. The conclusion of the Inquest was a narrative conclusion: Mr Mann underwent a necessary surgical procedure - Ivor Lewis surgery- on 23 May 2016. He had a poor post-operative recovery, which required prolonged ventilation. On 27" May 2016 he developed a pneumothorax. On the 27" May 2016 he also underwent a Visipaque contrast study. He should not have undergone the Visipaque procedure at that time, due to the pneumothorax. During the course of the Visipaque procedure, contrast entered the left main bronchus. Both the post-operative complication of pneumothorax and the entry of contrast material into the left main bronchus led to a deterioration in his respiratory state, from which he did not recover. 4 | CIRCUMSTANCES OF THE DEATH Mr Mann underwent an Ivor Lewis procedure for oesophageal cancer on the 234 May 2016. On the 27" May 2016 reduced entry into the left side of his chest was noted and an x-ray confirmed a large left sided pneumothorax. The surgical team requested a further chest x-ray at 2:30 pm. The consultant surgeon confirmed that this should have been carried out prior to the Visipaque procedure. The chest xray was not carried out and the Visipaque procedure took place at around 16:10 on the a7" May 2016. The independent radiology expert confirmed that from the very first image available to the radiologist, the left pneumothorax was apparent. The radiologist should not have commenced the swallow procedure. The procedure was commenced and contrast material was seen to enter the left main bronchus. Despite this, the procedure continued and further contrast material is seen entering the left lung. Following the procedure there was a clinical deterioration in Mr Mann’s respiratory condition. On the 28" May 2016 Mr Mann suffered a further deterioration in his clinical condition and required re-intubation and ventilation. From this time there was no significant or sustained recovery. He passed away in Queens Hospital on the 7" September 2016. The cause of death was found to be 1a: Acute Respiratory Distress Syndrome 1b: chemical pneumonitis and pneumothorax and 1c: Oesophageal Carcinoma (Ivor Lewis procedure). CORONER’S CONCERNS During the course of the Inquest evidence gave rise to the following matters of concern:- 1. An independent radiology expert confirmed that the left pneumothorax was clearly apparent from the imaging, prior to the swallow commencing. The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax. 2. The radiologist who performed the procedure did not check the radiology system prior to commencing the swallow procedure. Had she checked the system she would have seen the x-ray taken at 12:37 showing the large left pneumothorax. She would also have seen the outstanding request for a chest xray. Both the independent radiology expert and the Trust radiology witness (Dr G), confirmed that recent radiology should be checked by the radiologist prior to performing this procedure. 3. The radiologist continued with the procedure after becoming aware of the passage of contrast material into the left main bronchus. The consultant surgeon and independent radiologist confirmed that the procedure should have been abandoned at that stage. 4, There was no documentation available within the records of the amount of contrast handed to Mr Mann or the amount of contrast ingested by him. 5. The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken. The incident occurred over a year ago. Despite clear concerns being raised by the Consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the Inquest hearing. 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 10 August 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 ENN the CQC and the Director of Public Health, (Mr Mathew Cole). | 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. IDATE] 1¢.6- 17) [SIGNED sr coroners <4) —_
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.
Barking, Havering and Redbridge INHS| University Hospitals NHS Trust PRIVATE AND CONFIDENTIAL Queen's Hospital Her Majesty’s Senior Coroner Rom Valley Way, Romford, Essex RM7 OAG Walthamstow Coroner’s Court . Queen’s Road . www.bhrhospitals.nhs.uk E17 8QP W @BHR_hospitals Date: 9 August 2017 Our ref: 0319 Trust Response to Regulation 28 Report Dear Madam Kevin George Mann In Response to the Regulation 28 Report you made at the conclusion of the inquest into the above- named’s death on 15 June 2017, please find herewith the Trust’s Response. Brief Background Mr Mann underwent an Ivor Lewis procedure for oesophageal cancer on 23 May 2016. On the 27" May 2016 reduced entry into the left side of his chest was noted and an x-ray confirmed a large left- sided pneumothorax. The surgical team requested a further chest x-ray at 2:30pm. The consultant surgeon confirmed that this should have been carried out prior to the Visipaque procedure. The chest x- ray was not carried out and the Visipaque procedure took place at 16:10 on 27" May 2016. The independent radiology expert confirmed that from the very first image available to the radiologist, the left pneumothorax was apparent. The radiologist should not have commenced the swallow procedure. The procedure was commenced and contrast material was seen to enter the left main bronchus. Despite this, the procedure continued and further contrast material is seen entering the left lung. Following the procedure there was a clinical deterioration in Mr Mann’s respiratory condition. On the 28°" May 2016 Mr Mann suffered a further deterioration in his clinical condition and required re- intubation and ventilation. From this time there was no significant or sustained recovery. He passed away at Queens Hospital on the 7 September 2016. The cause of death was found to be 1a: Acute Respiratory Distress Syndrome 1b: Chemical Pneumonitis and Pneumothorax 1c: Oesophageal Carcinoma (Ivor Lewis procedure). Coroner’s Concerns 1. An independent radiology expert confirmed that the left pneumothorax was clearly apparent f ent eTy UCL Partners V7 PREP SMOKEFREE Chair: Dr Maureen Dalziel MD MBChB FFPH Chief Executive: Matthew Hopkins from the imaging, prior to the swallow commencing. The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax. 2. The radiologist who performed the procedure did not check the radiology system prior to commencing the swallow procedure. Had she checked the system she would have seen the x-ray taken at 12:37 showing a large left pneumothorax. She would also have seen the outstanding request for a chest x-ray. Both the independent radiology expert and the Trust’s radiology witness (Dr G) confirmed that recent radiology should be checked by the radiologist prior ti performing this procedure. 3. The radiologist continued with the procedure after becoming aware of the passage of contrast material into the left main bronchus. The consultant surgeon and independent radiologist confirmed that the procedure should have been abandoned at that stage. 4. There was no documentation available within the records of the amount of contrast handed to Mr Mann or the amount of contrast ingested by him. 5. The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken. The incident occurred over a year ago. Despite clear concerns being raised by the consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the inquest hearing. Trust Response The Trust accepts and acknowledges that there was clinical governance gap in relation to its Visipaque procedures. Asa result of the Regulation 28 report made in this case, the Trust has undertaken reflection on issues raised in this case and has gained insight on the lessons to be learned. The Trust’s Radiology Department has carried out an audit of Visipaque Swallows from May 2016 — June 2017 and will conduct a further audit three months after the revised Protocol (attached) has come into use to ensure understanding and compliance. If any issues are identified by the audit, the staff concerned will have 1:1 conversations with one of the Clinical Leads for Radiology and be required to undergo an observed procedure for assurance of skill. The updated protocol also recognizes the need for specific informed consent to be obtained from the patient prior to Radiology procedures being undertaken. Obtaining such consent is in line with guidance from the GMC, the Department of Health and is usually part of any NHS Trust’s consent policy. Whilst the Referring clinician (recommending the scan) has overall responsibility for the patient and has the most accurate clinical information on the patient, the Protocol provides communication guidelines between the Radiologist and the Referring clinician in order that any underlying pathology or existing comorbidities which may have a significant contrast risk can be noted and discussed, for the best clinical management of the patient prior to any radiology investigations being conducted. Patients will be continuously monitored when presenting for Visipaque swallow investigations — ay? Syme —~ es . SAFETY fel Partners or FREP terre ttt cy FET SMOKEFREE Chair: Dr Maureen Dalziel MD MBChB FFPH Chief Executive: Matthew Hopkins whether they are inpatients or outpatients and should any questions arise from the patient on the day of the scan or x-ray, appropriate clinicians will be available to answer those questions. | trust the above Response, with attached Protocol addresses your concerns. If | can be of any further assistance, please do not hesitate to contact me. Medical Director. SIs SAFETY UCL Fartners suoxenice + Aerts Uitte ct fe Chair: Dr Maureen Dalziel MD MBChB FFPH Chief Executive: Matthew Hopkins
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