Prevention of Future Deaths reports · 2017

James Vinson

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 report9 Aug 2017
Reference2017-0338
DeceasedJames Vinson
CoronerDerek Winter
Coroner areaSunderland
CategoryHospital Death (Clinical Procedures and medical management) 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.

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

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 City Hospitals Sunderland NHS Trust (PDF)
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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