Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0338, written 9 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Aug 2017 |
|---|---|
| Reference | 2017-0338 |
| Deceased | James Vinson |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Derek Winter DL Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Mr Ken W Bremner Chief Executive City Hospitals Sunderland NHS Foundation Trust Sunderland Royal Hospital Kayll Road Sunderland SR4 7TP CORONER Iam Derek Winter DL, Senior Coroner for the City of Sunderland 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. http:/Avww. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 23™ October 2016 Mr James Trevor Vinson aged 72 years died at Sunderland Royal Hospital. I concluded the Inquest as part of my investigation on gn August 2017 recording a conclusion of an Accident. The Cause of Death following Post-Mortem Examination was: - Ia Intra-Peritoneal Haemorrhage; Ib Splenic tear following fall; Contributed to by II Bronchopneumonia; Cirrhosis of the Liver; Malignant Lymphoma CIRCUMSTANCES OF THE DEATH Mr Vinson was a 72 year old man who, whilst in the USA, sustained an acute subdural haematoma, for which he was treated with a craniotomy on 16" September 2016. When in hospital in the USA he had one to one supervision, and on 2™ October 2016 a CT scan identified he had an enlarged spleen (16.5cm weighing 823g). Furthermore, he was identified as having a risk of falls and wore a wristband to that effect. On his escorted retum home he was admitted to Sunderland Royal Hospital Stroke Unit on 10" October 2016 for rehabilitation. On 13th October 2016 he was found on the floor of his hospital room where he was in Civic Centre, Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sunderlandcoroner.co.uk isolation for reasons of infection control. The fall was unwitnessed. On 16th October 2016 it was found that he had had a splenic laceration with an intra- peritoneal bleed. He remained unwell and was given palliative treatment until his death on 23rd October 2016 at 20:05 hours. The Post-Mortem Examination confirmed “the proximate cause of death to be a large intra- peritoneal bleed associated with capsular tears of the spleen. Very rarely such splenic ruptures are spontaneous but most are associated with trauma and the circumstances in which he was found indicate that this is most likely aetiology although no bruise could be identified on external examination of the body. Nevertheless, the spleen itself is intrinsically abnormal. It is markedly enlarged and soft and this has two underlying causes. Firstly, the post-mortem has revealed cirrhosis of the liver. Splenomegaly is a well-recognised association of this condition due to the complication of portal hypertension. Furthermore he has a haematological malignancy most in keeping with a high grade malignant lymphoma and the spleen is also enlarged due to infiltration by these atypical cells. These two natural disease processes have, therefore, caused the spleen to enlarge and make it more at risk to rupture from even mild trauma, although the latter has almost certainly been the precipitating event leading to his blood loss and subsequent demise”. 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. Although the Splenomegaly (identified in Sunderland Royal Hospital on 16" October 2016) would not have led to any changes in the management of Mr Vinson, I was concerned to hear in evidence, that Mr Vinson was meant to be under close supervision in his hospital room, but this was not the case despite a review of the falls risk assessment. I heard evidence about a draft Enhanced Care/Observation Standard Operating Procedure (SOP), and copies were provided to me and the family. Although a SOP is to be piloted, I am further concerned that the plans for its implementation are not clear. Hence this Report to you. I emphasised in Court that this Report is not to be construed as any form of censure, but rather a means to clarify the actions to be taken and firm timescales. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 6th October 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - e Family e Sunderland Royal Hospital and their Solicitors e Care Quality Commission (CQC) 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. Dated this 9” day of August 2017 Senior Coroner for the City of Sunderland
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.
City Hospitals Sunderland INHS| NHS Foundation Trust Chief Executive: Ken Bremner Sunderland Royal Hospital Kayll Road KWB/DC/JV Sunderland Tyne & Wear 22 September 2017 SR4 7TP Tel: 0191 565 6256 Ext: 42404 Fax: 0191 569 9642 Private & Confidential Email: Derek Winter Senior Coroner for the City of Sunderland Civic Centre Burdon Road Sunderland SR2 7DN New hy binhy, Dear Mr-Winter _ Regulation 28 Report to Prevent Future Deaths — Mr James Trevor Vinson | write further to your correspondence dated 9 August 2017 regarding your concerns identified during the inquest into Mr James Vinson’s death. | enclose with this letter an action plan which confirms: a) the actions that will be taken by the Trust in response to your concems; b) the target dates for completion of those actions; and c) the Officers with responsibility for progress of the actions. As you will note from the enclosed action plan, the Trust is currently developing an Enhanced Care Standard Operating Procedure (SOP) to assess vulnerable adult in-patients’ observation and care requirements. The SOP incorporates an Enhanced Care Risk Assessment Tool and defined criteria for heightened levels of observation. The purpose of this SOP is to ensure our staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within the stated criteria. One of the witnesses in her evidence at Mr Vinson’s inquest made reference to the draft SOP, however, you have expressed concerns regarding the lack of clarity around its implementation. | would like to advise you that we are currently piloting the draft SOP on a number of wards within the Trust, including the Acute Stroke Unit where Mr Vinson suffered his fall. As per the action plan, the target date for ratification and Trust-wide roll-out of the SOP is January 2018. We are also reviewing our Prevention and Management of Hospital-Based Falls Policy. The Falls Policy and the Enhanced Care SOP will be closely linked, so we have appointed the same Leads for both documents. The target date for completion of this review is November 2017. oe Moy, & Neurophysiology Department Seve fg Sunderland Eye Infirmary ° & Day Case Unit . 9 sp Chairman: John N Anderson QA CBE In association with the Universities of Newcastle, Sunderland and Northumbria www.sunderland.nhs.uk LP58339 WZI824 Progress of the actions detailed within the action plan will be overseen by our Executive Director of Nursing and Patient Experience who will keep me briefed and report to the Trust’s Clinical Governance Steering Group. On completion, this will be escalated to the Trust's Governance Committee which is a sub-Committee of the Trust Board as well as to the Trust Executive Committee. | trust this information provides assurance to you that the Trust has taken appropriate action to mitigate any future patient safety issues with regards to falls risk assessment and management. | would also like to take this opportunity to offer my sincere condolences to Mr Vinson’s family on behalf of myself and the Trust. Yours sincerely Ken —— _ Chief Executive
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