Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0285, written 10 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2017 |
|---|---|
| Reference | 2017-0285 |
| Deceased | Bernard Cosgrove |
| Coroner | Alan Wilson |
| Coroner area | Blackpool and Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| 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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Acting Chief Executive
Blackpool Teaching Hospitals NHS Foundation Trust
Blackpool Victoria Hospital
Whinney Heys Rd
Blackpool
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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
The medical cause of death was recorded as follows:
1 a Bronchopneumonia
1 b Chronic obstructive pulmonary disease
11 Severe coronary artery atheroma, Left ventricular hypertrophy, Pyelonephritis, Hip joint
infection associated with dislocated hip prosthesis
Narrative conclusion:
In December 2016 Bernard Cosgrove lost his balance as he made his way to his front door at
his home and suffered a fracture of his right neck of femur which was surgically repaired. On
28th February 2017 he was admitted to hospital after he had been observed to be
unresponsive. By the time he was discharged back to the care of the nursing home on 10th
March 2017 it had not been fully recognised that his right hip joint had become dislocated
during that period of hospitalisation and had started to become infected. He died at 0730
hours on 21st March 2017 at the nursing home where he resided from the effects of
bronchopneumonia which had developed after his discharge from hospital. A subsequent post
mortem examination confirmed his death was contributed to by significant heart disease and
the hip joint infection.
4
CIRCUMSTANCES OF THE DEATH
Please see Narrative conclusion in section 3 above.
1
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:
On 25th September 2017 I concluded this inquest by way of a narrative conclusion. I indicated
at the end of the inquest that it was my intention to write a report due to a concern about
future deaths. Mr Cosgrove found himself being discharged back to the nursing home from
where he had originally been admitted to hospital at a time when seemingly unknown to the
hospital staff - including a senior member of the nursing staff for the ward - he had a
dislocated hip. The fact that there was a problem with the hip seems to have become quickly
apparent to care home staff upon his return to that home and to a General Practitioner who
visited him although once the dislocation was in fact recognised it was treated conservatively
given the patient's co-morbidities.
The concerns are:
Despite an entry in the clinical records made by a doctor on 3rd March 2017 which
refers to a rotating right leg, neither the issue he identifies nor his entry in the notes
appear to have been appreciated by nursing staff who cared for Mr Cosgrove
thereafter. A Sister who was a clear and helpful witness acknowledged in court that
the issue identified by the doctor on 3rd March 2017 was not considered as part of his
plan of care subsequently. This is despite the fact that between 3rd March 2017 and
discharge from hospital he was seen regularly by staff with responsibility for
physically rolling him with a view to providing pressure relief.
Although from the evidence it is not known how the dislocation occurred the fact it
does not appear to have been recognised over a period of 7 days is concerning and
strongly suggests that staff paid insufficient regard to the patient’s previous medical
record entries. Patients such as Mr Cosgrove should not find themselves being
discharged from hospital in such circumstances and at a time when the medical
professionals looking after his welfare are unaware of such an issue.
But for the fact he was discharged from hospital on 10th March 2017 and that this
resulted in the dislocation problem being identified, had he spent a lengthier period
in hospital the dislocation and developing infection may well have continued to go
unrecognised which raises a concern about how effectively patients are being
monitored and their medical records are being considered by staff who are
subsequently involved in that patient’s care. On this occasion once the dislocation
issue was identified this did not substantially alter his care and he was treated
conservatively, but in other circumstances not recognising the problem may have
directly caused a death.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
6
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.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons :
The family of Bernard Cosgrove.
The Manager of New Victoria Nursing Home.
Care Quality Commission.
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 coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
8
9
A.A.Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 10th October 2017
3
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.
NHS} Blackpool Teaching Hospitals NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool FY3 8NR 15 December 2017 Mr Alan Wilson Senior Coroner for Blackpool & the Fylde Municipal Buildings Corporation Street Blackpool FY11GB Dear Mr Wilson Re: Regulation 28 Report to Prevent Future Deaths —- Bernard Cosgrove | write in response to your Regulation 28 report to prevent future deaths relating to the care of Mr Bernard Cosgrove. Having reviewed your Regulation 28 | initiated a review of the care which Mr Cosgrove received whilst an in-patient in the Trust. You have raised three concerns which | shall address in turn. 1. Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. It is acknowledged that, sadly, the necessity to x-ray Mr Cosgrove's hip was not acted upon post the recommendation on the 3% March 2017. The nursing staff continued with Mr Cosgrove’s plan of care until his discharge on the 10" March 2017, this included a strict turning regime given his susceptibility to developing pressure damage, which for a patient like Mr Cosgrove could have been fatal. The Trust cannot, identify why, in Mr Cosgrove’s case, there was no further record or action taken in terms of investigation into the potential findings from the 3° March 2017 and for this we apologise. However, having undertaken an internal review of Mr Cosgrove’s care, lessons have been learnt and are being implemented. 2. Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient’s previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. A problem with his hip was suspected by the attending Physician who ordered an x-ray on 3March 2017. Unfortunately this Physician was a locum who left on that date and the outstanding request for an x-ray investigation was not pursued by his successor who was also a locum. Since that time the Trust has introduced an electronic tracking system on every ward RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROW'S CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quatity up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. é eo yy INVESTORS (ee disability Health @ care | Chairman: Mr lan Johnson MA, LL.M. YY IN PEOPLE | Gold | (E69 confident eS tust | Chief Executive: Wendy Swift COMMITTED where critical activities are flagged until they have been actioned. The hip x-ray would now be identified as a critical activity and | can assure you that such an oversight could not now occur. 3. But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient’s care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death. The Trust notes your concern in terms of other potential circumstances where not recognising issues or recording specific history within patient notes could lead to future problems and we are working hard to eradicate such problems. We work closely with our staff in terms of practice development and continued professional development through Ward based education, updates and reminders of their professional responsibility in terms of patient care and contemporaneous recording of observations and notes. | hope the Trust’s response assists you in addressing your concerns. Yours sincerely MStorman PROFESSOR MARK O’DONNELL MEDICAL DIRECTOR
See every Prevention of Future Deaths report matching Blackpool Teaching Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.