Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0228, written 7 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 | 7 Sep 2017 |
|---|---|
| Reference | 2017-0228 |
| Deceased | Glenys Pollitt |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport Inhs NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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: Mrs Ann Barnes, Chief Executive, Stepping Hill Hospital CORONER lam Alison Mutch, senior coroner, for the coroner area of South Manchester 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 INVESTIGATION and INQUEST On 20" February 2017 | commenced an investigation into the death of Glenys Pollitt. The investigation concluded on the 14" August 2017 and the conclusion was one of Narrative: Died as a result of a recognised complication of Boerhaave Syndrome following an operation to repair the oesophageal tear carried out after it had been identified. The medical cause of death was 1a Multi-organ failure;1bBoerhaave syndrome; (I Atrial fibrillation 4 | CIRCUMSTANCES OF THE DEATH Glenys Pollitt was admitted to Stepping Hill Hospital on the 6th February 2017. She was examined and an x-ray taken at 23:50 on 6th February 2017. She was diagnosed with community acquired pneumonia. A surgical emphysema visible on the x-ray was not identified. She deteriorated. She was seen by a number of clinicians who reviewed her and the x-ray. The surgical emphysema was not identified. On 7th February 2017 at 12.30pm she was reviewed by a consultant who ordered a CT scan and requested critical care input. The scan showed extensive surgical emphysema and a diagnosis of an oesophageal rupture (Boerhaave Syndrome) was made. An emergency operation was carried out on 7th February 2017. She was moved to ICU following the operation. She deteriorated and died on the 16th February 2017 from multi-organ failure. 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. It was accepted during the evidence that the x ray should ideally be viewed on a high-resolution screen rather than an standard screen. This increased the likelihood of significant abnormalities being detected. There are a number of such high-resolution screens for viewing of x rays. The evidence indicated that there was differing practice across the hospital as to when such screens were used and by whom. 2. At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray. It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst clinicians; 3. The process for escalation to consultant level and critical care was unclear. 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 by 2™ 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 the followin Interested Persons namely and P| daughters of the deceased, who may find it useful or of interest. lam 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. ww Alison Mutch OBE HM Senior Coroner 7 September 2017
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.
Our ref. GPo-2065 Your ref. 6680/HC 2"! November 2017 Ms A Mutch H. M. Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch + CH fee Re: Glenys POLLITT (Deceased) Stockport INHS NHS Foundation Trust Oak House Stepping Hill Hospital Poplar Grove Stockport SK2 7JE Telephone: 0161 483 1010 Fax: 0161 487 3341 Direct line: 0161 419 5444 Thank you for your letter of 7 September 2017 concerning the inquest of the above named patient. As always, | am grateful to you for highlighting your concerns and for providing me with an opportunity to respond. As per your regulation 28 report to prevent future deaths, | will respond to each point as you have raised them: 1) It was accepted during the evidence that the x ray should ideally by viewed on a high- resolution screen rather than a standard screen. This increased the likelihood of significant abnormalities being detected. There are a number of such high-resolution screens for viewing of x rays. The evidence indicated that there was differing practice across the hospital as to when such screens were used and by whom. There are two high resolution screens available in the Emergency Department (ED) — one in the resuscitation room and one at the main base (where the doctors and nurses have access to multiple computers). High resolution screens are available to and used by the reporting radiologists in dimmed lighting quiet rooms. The log in to PACS (Picture Archiving and Communication System) is the same for staff regardless of what type of screen is attached to the computer terminal they are working on. The setup of images on the screens do differ which some staff may wish to have training for, which is available. ED staff are also available to support staff who are not used to looking at images on the high resolution screens whilst in ED if they are not familiar with these screens. The Trust's Radiology Systems Manager has confirmed that the standard screens available in ED are of a high enough resolution to view chest x ray images. The Radiology Systems Manager has drafted a document, which is awaiting their Business Group Quality Governance Board sign off, to list where all high resolution screens are within the Trust, how to access them and how to gain support to view images on them, should it be required. However, within our Trust serious incident investigation no member of staff stated that it was the screen resolution that impacted on their diagnosis. The root cause was found to be tunnel vision — the staff expected to see a chest infection and their likely diagnosis was confirmed by their view of the x ray. This confirmation bias led to staff not recognising the surgical emphysema on the chest x ray which in turn led to the delay of recognising the need for the patient to go to theatre. Page 1 of 2 2) At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray. It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst clinicians. Both the Emergency Department team and the Acute Medicine team have completed morbidity & mortality discussions regarding this case — completed on 15/02/2017 and 24/05/2017 respectively. These are perfect opportunities for cases to be shared with clinicians across all grades to review and learn from a case. Both departments have confirmed that they intend to use this case for future training of junior clinical staff in their ongoing training programmes. 3) The process for escalation to consultant level and critical care was unclear. During the evidence at the inquest it was confirmed that the Trust were using the Early Warning Score Escalation Pathway (EWS). At 04:39 07/02/2017 the patient was scoring an EWS of 6 (based on the EWS pathway parameters). The pathway states a middle grade should be contacted to discuss the patient's management and to review the patient if clinically indicted. On this occasion it is document in the ED record that the patient was being reviewed by the medical registrar at 05:15. The EWS pathway says to consider ICU referral for EWS = 5 to 7, it does not state a definite referral. During the inquest the patient's daughter asked why the Trust used the EWS pathway not the National Early Warning System (NEWS) as she believed the patient would have been escalated to the critical care team sooner based on the NEWS pathway. The evidence given in response was that though we were not using NEWS we had intended to change to it from 30/09/2017 when our new electronic patient record (ePR) was launched. Unfortunately this launch has been delayed and we do not have a definitive new launch date. Therefore our Assistant Director of Nursing, who has been tasked with rolling out NEWS across the Trust, is currently working up an implementation plan that is not reliant on the launch of our ePR. The NEWS would prompt consideration of escalation to critical care if the patient scored a 7 or higher. On review of the patient's observations in the Emergency Department, based on NEWS, the patient would have triggered for consideration of transfer to critical care at 01:54, 07/02/2017. On the assumption that critical care would have attended following escalation at that time, it is probable that the patient would have been planned for surgery as it is likely a CT scan would have occurred sooner. | hope that this response addresses your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact mie if you have any further questions regarding this matter. Yours sincerely nn\Barnes Chief\Executive Page 2 of 2
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