Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0343, written 31 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 | 31 Oct 2017 |
|---|---|
| Reference | 2017-0343 |
| Deceased | William Bergman |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
William Henry BERGMAN (died 20.12.16)
THIS REPORT IS BEING SENT TO:
1. Dr Alistair Chesser
Chief Medical Officer
Barts Health
Royal London Hospital
Whitechapel Road
London E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 29 December 2016, one of my assistant coroners, Sarah Bourke,
commenced an investigation into the death of William Bergman, aged 88
years. The investigation concluded at the end of the inquest earlier today.
The jury made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Mr Bergman, who suffered with vascular dementia, was admitted to the
Royal London Hospital and diagnosed with pneumonia. He died
following an impact to his forehead sustained while healthcare assistants
were changing him on 19 December 2016, variously described as hitting
it on the cot side or on the side of the nearby television.
1
His deterioration was noted several hours after the incident, and when
he was then scanned, he was found to have sustained a subdural
haematoma and a massive intracranial bleed.
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.
The staff nurse who was called to see Mr Bergman after the accident,
quickly formed the opinion that he was fine.
Although the medical records were not available for consideration
because Barts Health has been unable to locate them, she said that she
would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated.
She did not ask for immediate neurological observations, then to be
repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor
head injury in an elderly person with vascular dementia and liver cirrhosis
having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman
that day described as being accompanied by a lump) some hours later,
she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s
death.
The staff nurse said in court how sorry she was that she had not acted
differently, and described her contact with Mr Bergman as career
changing.
The reason I write to you now is because if one staff nurse responded in
this way to a head injury, immediately assuming that it was minor and
therefore with minor consequences, then others may behave in the same
way.
6
ACTION SHOULD BE TAKEN
2
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 2 January 2018. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, daughter of William Bergman
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
31.10.17
3
ell INHS Barts Health NHS Trust Senior Coroner for Inner North London Barts Health NHS Trust St Pancras Coroner’s Court Trust Executive Offices Camley Street Ground floor, Pathology Block London The Royal London Hospital N1C 4PP London, E1 2ES Telephone: 020 32460632 21°' December 2017 www. bartshealth.nhs.uk By special delivery Dear Ms Hassell | write in response to your Regulation 28: Report to Prevent Future Deaths, dated 31 October 2017. Your concerns are related to the standard of nursing care provided to William Henry BERGMAN (died 20.12.16). This by an individual staff nurse and following a minor accident and head injury he sustained while an inpatient at the Royal London Hospital. These are concerns about lack of observation and escalation by the staff nurse and failure to recognise or act on potential risk factors which developed later. Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018). A trust safety notice was also distributed site wide warning other wards in our hospital group of the risks associated with post head injury management. Finally | can advise that The Royal London Senior Management Team are commissioning an internal concise serious incident investigation to review the trusts handling of this case post death and are in the process of compiling an investigation case file to facilitate this (to be finalized by February 28" 2018). Thank you for bringing your concerns to my attention. | trust that you are assured | have taken them seriously and investigated them appropriately. Yours faithfully Dr Simon Harrod Medical Director Royal London Hospital cc Legal Services a Director of Nursing & Governance Royal London Hospital
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