Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0215, written 13 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Sep 2017 |
|---|---|
| Reference | 2017-0215 |
| Deceased | Bronwyn Williams |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Bronwyn Ann WILLIAMS (died 23.05.17)
THIS REPORT IS BEING SENT TO:
Principal Dentist
Kindandental
99 Newington Green Road
Mildmay Ward
London N1 4QY
1.
2.
Medical Director
Homerton University Hospital NHS Trust
Homerton Row
London E9 6SR
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 25 May 2017 I commenced an investigation into the death of Bronwyn
Williams, aged 68 years. The investigation concluded at the end of the
inquest on 4 September 2017. I made a determination as follows.
Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess.
This is a naturally occurring, albeit rare condition. She had consulted at
an accident and emergency unit on 1 May 2017 and been referred to a
dentist.
1
She saw her dentist on 4 May 2017 and was referred to a maxillofacial
unit. She was due to be seen within two weeks, but the dental surgery
system of referral was postal rather than electronic and then the hospital
did not provide an appointment within two weeks, so she was not seen
again before her death.
Her medical cause of death was:
1a septicaemia/mediastinitis
1b retropharyngeal abscess
1c gum infection
2 type II diabetes mellitus
4
CIRCUMSTANCES OF THE DEATH
Ms Williams saw a dentist at Kindandental on 4 May 2017, having
attended the emergency unit of Homerton University Hospital on 1 May
and been told to visit her dentist, complaining of pain preventing mouth
opening other than to a very limited extent, and a general malaise.
Neither intra oral examination nor imaging was possible at the dental
surgery, because of the extent of the trismus. The dentist therefore
prescribed a five day course of antibiotics and referred Ms Williams to
the maxillofacial unit of the Homerton on an urgent basis. The word
urgent in this context means that an appointment should be fixed to take
place within two weeks.
On 10 May, Ms Williams rang the dental surgery to say that she had seen
on her copy of the referral that her road name had been misspelled and
her postcode had been omitted. This was rectified and a further referral
sent to the Homerton.
Ms Williams died before ever receiving her appointment.
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.
Some matters have already been dealt with following Ms Williams’ death.
However, MATTERS OF CONCERN remain as follows.
1. I heard at inquest that the urgent referral from Kindandental to the
Homerton was made not by logging on to a portal, or by email, or
by fax, but by post. This seems unduly slow, cumbersome and
prone to mishap.
2
2. Following Ms Williams’ attendance at the dental surgery on 4 May,
an appointment with the maxillofacial unit was made for 30 May,
then cancelled by the Homerton on 23 May and re-fixed for 19
June. This date is nearly seven weeks post referral.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 13 November 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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, son of Bronwyn Williams
I 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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
13.09.17
3
2 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.
Homerton University Hospital Trust offices Education Centre Homerton Row London E9 6SR Tel: 020 8510 7244 Fax: 020 8510 7608 www.homerton.nhs.uk 13th November 2017 Strictly Private & Confidential Senior Coroner Hassell Inner North London St Pancreas Coroner’s Court By email to Coroner’s office: Dear Coroner Hassell, Re: Inquest touching the death of Bronwyn Williams- Prevention of Future Deaths Report Thank you for your email sent on 15th September 2017, which contained a Prevention of Future Deaths (PFD) report dated 13th September 2017, in which you raised the following concerns; 1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap 2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral. I have attached the action plan developed in response to the PFD notice. We are one of the most advanced Trusts in London in relation to fully implementing electronic referrals via the e- RS system, known as Choose and Book, for GPs by April 2018. Unfortunately, although the system could in theory accept referrals from dentists, in practice they cannot use the system for reasons discussed in the action plan. We cannot fix these issues locally, and are therefore taking actions to mitigate the risk that necessarily remains. I do hope that this information and our action plan provides you with assurance that we are addressing these issues. Please do not hesitate to contact me if you require any further information or wish to discuss this matter further. Yours sincerely, Dr Martin Kuper Medical Director Homerton University Hospital Enc: Homerton University Hospital NHS Foundation Trust Action Plan. Incorporating hospital and community health services, teaching and research
and Associates
99 Newington Green Road, London N1 4QY
020 7226 3897/6215
info@kindandental.com
www.kindandental.com
Wednesday 20th September 2017
RE: Prevention of Deaths Report
Bronwyn Ann WILLIAMS (died 23-May-17)
Dear Sirs
In response to the Coroner’s concerns detailed in the report dated 13th Sep 2017 this
letter details the action taken by Kindandental to reduce the risk of a similar incident
occurring.
We have applied, and have subsequently provided the pre-requisite information
required, for the use of an NHS net email address. This is the email system for NHS
electronic referrals (to comply with NHS patient confidentiality requirements).
We anticipate having this available to us within two weeks, the timeframe indicated
to us by NHS net email providers. We further anticipate starting to send referrals
using the NHS net email service as soon as this is in place and within a further
period of two weeks having trained all staff internally to be fully using this service and
no longer sending patient referrals via post.
The specific reason that we have not been using electronic referrals to this point is
due to technical issues with NHS net email in the past. We have investigated usage
of NHS net email by dental practices and it is not commonly used by NHS dental
practices in our locality. We had been formerly informed that use of NHS electronic
referrals must be via NHS net email only, for reasons of patient confidentiality.
However, our Significant Event investigations recently following the Coroners letter
have revealed that we are, in fact, able to send electronic referrals via other email
services where we have a patients’ explicit written consent to do so, although we
cannot have a confirmation email returned to us acknowledging receipt. This is of
interest as it means if we experience any future technical issues with NHS net email
we have an alternative electronic means of NHS referral. We anticipate having
functionality built into our existing computer system for this within two weeks.
_________________________________________________
www,k i n d a n d e n t a l .com
and Associates
99 Newington Green Road, London N1 4QY
020 7226 3897/6215
info@kindandental.com
www.kindandental.com
We have also reviewed our referral pathways and fully updated the information
therein. This has been disseminated to all dentists via email. Our computer system
logs and manages referrals. We have reviewed this process and re-iterated to staff
the importance of all referrals being fully and correctly logged. Our protocol for all
referrals has been reviewed and a check list has been created to be followed and
adhered to so that correct and up to date information is gathered for the referral. The
check list is a laminated document displayed in each surgery.
We have communicated to all staff (via email and in person) the importance of
verifying patient information, full address including post code and GP details, at all
points where a referral is made and additionally at general check up appointments.
Sincerely,
Principal Dentist
_________________________________________________
www,k i n d a n d e n t a l .com
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