Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0191, 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 | 2017-0191 |
| Deceased | Lily Townsend |
| 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, Sandwell and West Birmingham Hospitals NHS Trust. 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 25 April 2017, I commenced an investigation into the death of the late Mrs Lily Townsend. The investigation concluded at the end of the inquest on 12 June 2017. The conclusion of the inquest was a short narrative conclusion of: “Died after developing a rare but recognised complication of pulmonary fat embolism due to bone cement implantation syndrome.” The cause of death was: 1a Pulmonary Fat Embolism b Bone Cement Implantation Syndrome c II Ischaemic Heart Disease and Pulmonary Fibrosis 4 CIRCUMSTANCES OF THE DEATH i) Mrs Townsend had an unwitnessed fall at home in her bathroom on the evening of 11 February 2017 and was admitted to Sandwell Hospital on the 12 February. ii) She had a medical history including cancer, severe cardio pulmonary disease, atrial fibrillation and pulmonary fibrosis. A fractured neck of femur was diagnosed. iii) Inadequate medical history was taken during the preoperative assessment and a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension. iv) On the 13 February, she underwent cemented hemiarthoplasty and when the cement was applied her oxygen saturation and blood pressure dropped rapidly and despite attempts at resuscitation she was pronounced deceased at 1pm. 1 [IL1: PROTECT] 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 during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial ischaemic heart disease and pulmonary hypertension. infarction, 2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given. 3. The risks of the procedure may have been reduced by performing an un- cemented operation given the known potential cardiopulmonary complications of cement. 4. The Trust initiated an internal investigation and identified that the root causes were: a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk. b) Consent process inadequate. 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. Given the finding of the recent audit (Assessment of documentation of risks for hip fracture patients June 2017) to check compliance that documentation of risk discussion has been completed. It is disappointing to note that it was only completed satisfactorily in 8 out of 18 patients. The overall documentation and risk discussion remains poor during both preoperative and post-operative phases. You may wish to consider setting up an urgent review of the issues identified and consider appropriate action to improve compliance. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 August 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 2 [IL1: PROTECT] 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 15 June 2017 Mr Zafar Siddique Senior Coroner Black Country Area 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.
Trust Headquarters Health & Wellbeing Suite Sandwell Hospital Lyndon West Bromwich B71 4HJ Tel: 0121 507 4871 Direct email: Diary through: Sent via email to: 11 August 2017 Mr Zafar Siddique Senior Coroner, Black Country Area Black Country Coroner's Court Jack Judge House, Halesowen Street Oldbury West Midlands B69 2AJ Dear Mr Siddique Response to the Regulation 28 Report – the late Mrs Lily Townsend I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 12 June 2017, in respect of the late Lily Townsend. I should extend again the condolences of the Trust to Mrs Townsend’s family, to whom I am copying this letter. The important issues you raise have been taken very seriously within the Trust. I attach a presentation by the relevant clinical team which sets out their promises to us about how they will change their service. This is being tracked each month by the Clinical Group Management team using a data scorecard (also attached). The consultant body within orthopaedics, geriatric medicine and anaesthetics attended, with other professionals, a Safety Summit which I chaired. Here we discussed the issues which had given rise to your report, and the planned actions. The summit was also attended by our medical and nursing directors, and the non-executive chair of our Quality and Safety Committee. The Trust's Board are fully involved with the improvement required. One issue you notified me about relates to our practice around high risk patients, where a ‘do not resuscitate order’ may be relevant. Since August 1st, recording such orders on a specific computer system within the Trust has become a requirement underpinned by disciplinary action for deviation. This allows us to ensure the quality of each order is assessed. I should be clear that our audit data to date attests to good quality decision making and involvement but we are striving for excellence. I anticipate the majority of the actions in the plan being complete by the end of October and will write to you again in November to update you on the status of our work. Do contact me, or my colleague or concerns. Yours sincerely, should this documentation give rise to questions Toby Lewis Chief Executive Enclosures cc Miss Townsend’s family Care Quality Commission NHS England , Director of Governance , Chief Nurse , Medical Director 2 | P a g e
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