Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0193, written 16 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 | 16 Jun 2017 |
|---|---|
| Reference | 2017-0193 |
| Deceased | Dianne Macrae |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
CIRCUMSTANCES OF THE DEATH See Narrative in section 3. 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 could 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) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 1 June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) Ail persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation, 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 by August 2017. 1, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:-. 1. MDU Solicitors 2. Bircham Dyson Bell Solicitors 3. Capsticks 4. BLM Solicitors 5. Kennedy's Solicitors 6. Similarly, you are 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. [DATE] [SIGNED BY CORONERl
REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Royal College of Anaesthetists Royal College of Surgeons Department of Health Nursing and Midwifery Council Kettering General Hospital Woodlands Hospital CORONER I am Anne Mary Christine Pember, Senior Coroner for the coroner area of Northampton. 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. INVESTIGATION and INQUEST On 23"' June 2016 an Investigation was commenced into the death of Dianne Jane MACRAE. The investigation concluded by way of inquest on 17"^ and IS'" May 2017. The medical cause of death was:- 1a) Multi organ failure b) Haemorrhage c) left common iliac trauma related to spinal surgery 1 June 2016 A narrative conclusion was given as follows:- Dianne Jane Macrae was admitted to the Woodlands Hospital Kettering on 11*" June 2016 for elective spinal surgery. The surgery was uneventful. Whilst in recovery she had dips in her blood pressure. She was cared for and treated by attending anaesthetists. Her Consultant Spinal Surgeon was not contacted in a timely fashion and not asked to attend. Her haemoglobin level was not obtained. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause for her instability. Her condition deteriorated. She was conveyed to Kettering General Hospital where she underwent further surgery. It was found she had suffered trauma to her left common iliac artery during the earlier surgical procedure. She was confirmed deceased at Kettering General Hospital on 13"' June 2016 at 16.25 hours. She died as a consequence of a rare but recognised complication of surgery.
4 responses 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.
T; E: W: www.gov.uk Department of Health Office of the Chief Medical Officer Richmond House 79 Whitehall London SW1A 2NS Our reference: Your reference: Mrs A Pember MM Senior Coroner Northamptonshire 110 Whitworth Road Northampton NN14HJ Wednesday 30'^ August 2017 Thank you for your letter of 14 June 2017 about the death of Mrs Dianne Macrae. I was very saddened to read of the circumstances surrounding Mrs Macrae's death. Please pass my condolences to her family and loved ones. I have noted very carefully the conclusion of the inquest and the areas of concern you have detailed. I can appreciate how distressing these circumstances must be for Mrs Macrae's family. Your concern is that those involved in the management of patients undergoing similar elective spinal surgery are aware that internal haemorrhage is a rare but recognised complication. You also issued your Report to the Royal College of Surgeons, the Royal College of Anaesthetists and the Nursing and Midwifery Council and I am advised that they have replied to you on this point. I hope their replies have been helpful. I am advised that the Royal College of Surgeons has brought your concern to the attention of the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS), who have written to their members. The SBNS and BASS have recommended a number of learning points including increasing patient awareness of the risk of major vascular injury: educational learning for all staff involved in this area of surgery; and ensuring there are clear arrangements in place for access to urgent vascular imaging and acute services. I am further advised that the Royal College of Anaesthetists is taking action to increase awareness of the possibility of concealed haemorrhage resulting from spinal surgery through patient safety bulletins, e-learning and other educational material.
Anne Pember HM Coroner for the County of Northampton 10 Whitworth Road Northampton NN1 4HJ 11 August 2017 Dear Madam Re: Dianne Jane MACRAE (deceased) – Letter to prevent future deaths Further to your report to prevent future deaths made under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013, I am writing to provide you with our response. I note your concerns about the need for all persons caring for a patient undergoing routine lumber decompression and discectomy to be aware that internal haemorrhage is a rare but recognised complication of surgery. I also note that no concerns have been raised about the conduct of any individual nurse involved in the care provided to Mrs Macrae. We are the UK regulator of registered nurses and midwives. Our principal functions are to establish the standards of education, training, conduct and performance for nurses and midwives and to ensure their maintenance. Our overarching objective is to protect the public, including by promoting and maintaining both proper professional standards and public confidence in the professions we regulate. We are currently undertaking a wholesale review of our education standards, including the pre-registration standards of proficiency that nurses must meet before being registered with us. We intend that these new standards of proficiency for registered nurses will include specific standards relating to patient assessment and the management of patient deterioration. We are undertaking a full public consultation on the draft standards, which is due to conclude on 12 September 2017, following which we will carefully review the feedback we receive from our stakeholders before finalising the standards. We will also take into account the concerns you have raised in your report about complications of surgery. Please note that as there are currently about 612,274 nurses and midwives on our register working in many different areas of practice across the UK, it is not our usual practice to issue specific clinical advice to nurses and midwives about individual cases. Such clinical advice may be more appropriately raised by relevant employers or on occasion by the Department of Health, NHS England ( or the NHS leadership in the devolved administrations) , or the National Institute for Health and Care Excellence (NICE). We will be sharing our response with the Department of Health. If you have any further concerns arising from this case which you consider fall within the NMC’s regulatory remit and which I have not addressed in this letter, please do not hesitate to contact me again. Yours faithfully Jackie Smith Chief Executive and Registrar Page 2 of 2
FROM THE PRESIDENT Mrs A Pember HM Senior Coroner for Northamptonshire 110 Whitworth Road Northampton NN14HJ Royal College of Surgeons ADVANCING SURGICAL CARE 8 August 2017 Dear Mrs Pember, 1 am writing in response to your letter dated 16 June 2017 regarding an inquest held on 17 and 18 May 2017 and the Regulation 28 report you enclosed. It was saddening to learn of the death of Mrs Macrae following elective spinal surgery but I thank you for sharing this Information with us. The College has followed your direction to consider what actions it could take to try to help to prevent future deaths of this kind. We have shared your letter with our colleagues In the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS) and discussed with them how best to do this. The Presidents of SBNS and BASS have jointly prepared a letter to send to their members, highlighting a number of learning points. I have enclosed a copy of this letter for you information. Yours Sincerely President, Royal College of Surgeons The Royal College of Surgeons of England 35-43 Lincoln's Inn Fields London WC2A3PE T: 020 7869 6009 E: president@rcseng.ac.uk W; www.rcseng.ac.uk Registered Charity No. 212808 «S« iI BASS British Association of Spine Surgeons 31st July 2017 To all BASS and SBNS members and trainees Dear Colleagues In response to a recent regulation 28 Coroner's report concerning major vascular damage during lumbar discectomy, we are writing to confirm the position of the SBNS and BASS in relation to the awareness and management of this rare and recognised event. It is recognised that this event occurs rarely with an incidence of approximately 1-4000 cases, but is associated with significant morbidity and mortality. We recommend: 1. That during the consent procedure for lumbar discectomy the risk of major vascular injury is disclosed and discussed. 2. Regular educational programmes to emphasise that the risk of major vascular injury anterior to the vertebral column should be considered within the differential diagnosis of peri/post operative hypotension during or after apparently straightforward lumbar discectomy . This should involve all staff engaged in the assessment and management of patients undergoing spinal surgery. 3. We recommend that all providers of spinal surgery have clearly agreed and established protocols for the provision of the appropriate access to urgent vascular Imaging and acute vascular services, so that in the rare event of a major vascular injury during lumbar discectomy, expeditious access/transfer to these services are present. SBNS President A/B. President BASS Sodety of British Neurological Surgeons at The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE Tel: 020 7869 6892 Fax: 020 7869 6888 E-mail: admln@sbns.org.uk Web: www.sbns.org.uk Registered Charity Number 1119431 VAT No. 983 8235 78 A Limited Company registered In England and Wales Number 5879644
WOODLAND HOSPITAL Woodland Hospital Rothwell Road, Kettering Northants NN16 8XF T: +44 (0)1536 414 515 F: +44(0)1536 412 155 www.woodlandhospital.co.uk Mrs A Pember HM Coroner for the County of Northampton 110 Whitworth Road Northampton NN14HJ 8^ August 2017 Dear Madam In response to your Regulation 28 letter to prevent future deaths following the Inquest touching the life of DIanne Jane Macrae, notwithstanding your previous Indication that Woodland were not required to respond. For completeness, I can confirm the hospital has considered and taken action for each point of cause for concern you have raised, this includes but is not exclusive to the following action. The hospital has reflected on the case at Clinical Governance Committee, and will reiterate the findings and conclusion of the Inquest at the next Medical Advisory Committee, 20'^ September 2017. The case and the learning points were also discussed at the theatre team meeting, and will be included at a reflective learning session in the next three months, which is led by Matron. As standard practice now since this tragic outcome, if an anaesthetist or surgeon is re-called to the hospital, both Consultant Surgeon and Consultant Anaesthetist are asked to attend. The Senior Management Team (SMT) who provide on call support 24/7 are all very clear on this and ensure this happens as part of the escalation process for any deteriorating patient, or when a Consultant is asked to return to the hospital. The new Matron is in the process of establishing a multi-disciplinary deteriorating patient committee where cases are discussed, to establish learning from incidents and near misses, the findings will also be published in the new "Clinical Matters" staff and Consultant Newsletter. Ramsay Health Care UK Operations Limited Registered Office; 1 Hassett Street, Bedford. MK40 IHA Registered in England No. 1532937 People caring for people www.ramsayhealth.com • The spinal neuro surgeons and Consultant anaesthetists working at the hospital are very aware of this case and now have a high suspicion to exclude post-operative internal bleeding. The holistic learning from this case will be shared with all Consultants following the Medical Advisory Committee meeting on the 20*'' September 2017 via our Consultant Newsletter. • A bed side Haemocue machine has been installed in recovery, to allow patient bedside testing of haemoglobin by recovery staff. This enables recovery staff to initiate this test as part of their observations to inform attending clinicians of the haemoglobin level in the instance of a deteriorating patient. • An emergency skills drill was undertaken in recovery in May 2017, and a programme of such drills is being rolled out through the clinical areas involving Consultant Anaesthetists. The hospital would like to reiterate their condolences to the family of Dianne Jane Macrae, and confirm that the action in relation to the matters of concern that you have raised have been addressed as outlined above. If you require any further information please do not hesitate to contact me. Kind regards. Yours sincerely General Manager
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