Prevention of Future Deaths reports · 2017

John Griffiths

Regulation 28 report to prevent future deaths, reference 2017-0222, written 11 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report11 Sep 2017
Reference2017-0222
DeceasedJohn Griffiths
CoronerNigel Meadows
Coroner areaManchester City
CategoryCommunity health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS .

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

e Medical Director of UHSM — hi

Copied for interest to:
e Chief Coroner
e Family of Deceased
° ERRE— GP. Comish Way Group Practise

CORONER

| am Nigel Meadows, H.M. Senior Coroner for the area of Manchester
City.

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.

INQUEST

| resumed and concluded the inquest into the death of Mr John Griffiths
on 5 September 2017 and recorded that he died from:

1a Pneumonia an acute left ventricular failure
1b Ischaemic heart disease

| recorded a conclusion ultimately of death from Natural Causes.

CIRCUMSTANCES OF THE DEATH

The deceased was born 19 June 1936 and was 79 years of age. He had
a general medical history of suffering from an abdominal aneurism which
was treated surgically over 20 years ago. He also suffered a heart attack
over 10 years ago and was treated by PCI-Stenting. He also suffered
from hypertension, chronic kidney disease, previous deep vein
thrombosis and vitamin D deficiency. He had an occupational history of
exposure to asbestos and had an in live diagnosis plural plaques and
asbestosis. He was being prescribed a combination of mediation for his
condition and initially presented at his GP on 4 December 2015
complaining of weight loss and gastrointestinal symptoms. He was
referred for the urgent suspected cancer pathway and was seen in the
gastroenterology clinic on 16 December 2016, which resulted in a
diagnosis of a hiatus hernia and diverticular disease.

He consulted his GP again on 2 February 2016 and he was referred to
dieticians for nutritional support and advice.

He consulted his GP again on 1 March 2016 with a chest condition and
was a general discussion of his recent CT scan and a request for a
further CT scan to be performed.

The deceased had a very supportive family and on 3 March 2016 he
presented at the Emergency Department of UHSM and then was referred
to the Respiratory Team after his chest x-ray and his reported history of
weight loss and increasing shortness of breath over the previous three
months of so. It appears that a junior doctor may have wrongly
interpreted the presence of plural plaques as being an indication of
malignancy and unfortunately the deceased and his family were left with
that impression.

He was admitted to Doyle Ward and it was noted that he had a raised
troponin and then a further raised level when it was retested. Ultimately
he was not further reviewed by the cardiology team and it was suggested
that he self-discharged but was advised to consult his own GP.
Unfortunately no discharge summary was subsequently completed and
forwarded to his GP.

After being discharged he went to see his GP on 4 March 2016 and saw
a locum GP. They managed to contact UHSM and speak to an on-call
cardiology registrar and obtain some records. It was noticed that there
had been some ECG changes and there was a recommendation for a
referral to the cardiology team. Unfortunately the locum GP, although
recording in the medical records that they had made the referral, failed to
properly follow the formal GP Cardiology Review Referral process and
ultimately that resulted in no formal referral being made.

This was not discovered until after the deceased died and the GP
practice carried out their own Significant Event Analysis. He had further
GP contacts on 18 and 24 March 2017 but then attended UHSM
Emergency Department on 28 March 2017 with a recorded history of 1/52
increasing shortness of breath. A chest x-ray was obtained but he was
diagnosed with anxiety and a lower respiratory tract infection and
discharged home with antibiotics and steroids. It does not appear that
the Emergency Department were aware of his previous cardiac history or
his admission on 3 March 2017, and the ECG results. The old notes
were not available and it does not appear that such electronic records
that did exist of the attendance on 3 March were reviewed and
considered.

UHSM subsequently conducted its own Incident Investigation and
recognised this as s missed opportunity.

The GP Practice did have an appropriate system of formal referrals and it
is unclear why the locum doctor failed to follow that process. Since the
event they have reinforced the training and awareness of the referral
process for all GPs in the surgery as well as trying to ensure that the
same GP sees patients regularly in order to achieve consistency.

It is understood that UHSM is introducing in a phased fashion electronic
medical records and that all medical records in the emergency

department should become electronically. In the present case they were
limited electronic reports but paper records could not quickly or easily be
recovered.

It is understood that in the coming months UHSM will be merging with
another major NHS Trust to create one of the largest Trusts in the country
and it its hoped that there will be consistent practise and procedures
across the entirety of the Trusts sites and in particular in the respective
emergency departments.

The deceased's condition continued to deteriorate and on 1 April 2016
the family made contact with the GP practice requesting a visit. His
reported symptoms did not indicate an acute condition appropriate for
such a visit and in any event the particular GP had other responsibilities.
He planned, however, to visit the deceased on 4 April 2017. However on
3 April the deceased had a cardiac arrest at home and although given
bystander CPR and the ambulance service attending he had a significant
period of cardiac cessation. He was taken to the emergency department
of UHSM where further resuscitation took place but his condition
deteriorated and he died on 8 April 2016.

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. UHSM did not appear to have a system or process that when
patients attend the emergency department it is checked whether or
not they have had any recent relevant presentations or

admissions.

. Ifso, then appropriate records are accessed and considered
including the results of previous relevant investigations and
assessments. If a completely electronic patient record is
introduced then this gives the opportunity for that to be achieved
easily. Unless and until that occurs other checking processes

need to be considered.

3. The learning from these events needs to be shared with the new
Trust.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by Wednesday 8" November 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 Interested

Persons. | have also sent it to organisations who may find it useful or of
interest.

| 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.

Nigel Meadows
HM Senior Coroner for Manchester Area 11/09/2017

Responses

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.

Response from Uhsm (PDF)
N°, University Hospital
UHSM of South Manchester [i7z59

Your Hospital NHS Foundation Trust

Wythenshawe Hospital
Southmoor Road
Wythenshawe
Manchester

M23 9LT

mi? | 0161 998 7070

= ere ES Siiene www.uhsm.nhs.uk

Private and Confidential
HMC Nigel Meadows
Senior Coroner Manchester (City) Area

By email: n.meadows@manchester.gov.uk
26 September 2017
Dear Mr Meadows

Thank you for raising your concerns at the recent inquest into the death of Mr John Griffiths. Please
find below the response of University Hospital of South Manchester NHS Foundation Trust (UHSM)
following the inquest into the death of John Griffiths and the Regulation 28 Report which you issued
on 12 September 2017.

Your concerns were set out in the Regulation 28 Report as follows:

1. UHSM did not appear to have a system or process that when patients attend the emergency
department it is checked whether or not they have had any recent relevant presentations or
admissions.

2. If so, then appropriate records are accessed and considered including the results of previous
relevant investigations and assessments if a completely electronic patient record is introduced
then this gives the opportunity for that to be achieved easily. Unless and until that occurs other
checking processes need to be considered.

3. The learning from these events needs to be shared with the new Trust
Response of University Hospitals South Manchester NHS Foundation Trust

The ED system puts an alert on the front of the attending patient’s card when the patient’s details are
entered into the system, which identifies how many previous attendances the patient has had in the
last 2 years. An alert runs across the top of the electronic record as a prompt for the clinician to refer
back to previous attendances if required. When Mr Griffiths attended on the 28 March 2017, the
system successfully identified that he had attended once in the last 3 months and twice in the last 2
years. The Emergency Department will attempt to take a history from the patient and collateral history
from those in attendance with them. The decision to refer back to the earlier admission on the
electronic record is an individual decision and the alert is a prompt within the system to ensure the
clinician is aware of previous attendances.

As described by [J within her evidence the systems in place to identify a patient’s relevant
clinical history when presenting at the Emergency Department will be enhanced by the introduction of

= ‘ & NBOy, wy
y Fy OVE Chief Executive — Silas Nicholls You
sat Ws Chairman — Barry Clare — Tub

INVESTOR IN PEOPLE

YL University Hospital
UHSM of South Manchester

Your Hospital NHS Foundation Trust

the Electronic Patient Record System (EPR) which is envisaged to be phased into use later in the
year (roll out is intended to be November 2017).

| can confirm that the Trust will share your report and this response with the board of the new Trust.

The Trust takes all concerns extremely seriously and patient safety is its priority. We hope that our
response corroborates the information provided to you during the inquest hearing and assuages your
concern in this regard.

VAC Le

University Hospital of South Manchester

Yours sincerely,

Toli Onon
Medical Di r

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