Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0348, written 4 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2017 |
|---|---|
| Reference | 2017-0348 |
| Deceased | Dorothy Breislin |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
Stuart P G Fisher HM Senior Coroner County of Lincolnshire 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: 1. Dr Neill Hepburn, Medical Director, United Lincolnshire Hospitals NHS Trust, Robey House, Lincoln County Hospital, Greetwell Road, Lincolnshire, LN2 5QY : CORONER | lam Paul S Cooper, Assistant Coroner for the Coroner's area of Lincolnshire. 2 | 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. 3 | INVESTIGATION and INQUEST On 3 February 2015 | commenced an investigation into the death of Dorothy Doreen BREISLIN, age 89. The investigation concluded at the end of the inquest on 29" November 2017. The conclusion of the inquest was Narrative. [4 CIRCUMSTANCES OF THE DEATH The deceased was admitted to the Pilgrim Hospital, Fishtoft on 18th January 2015 following a fall at home. She was initially treated for a pulmonary embolism. A later diagnosis revealed a fracture of the 8th rib on the right side that led to massive bleeding and eventually her demise. 4 Lindum Road, Lincoln, Lincolnshire, LN2 1NN ’ TEL: (01522) 552500 FAX: (01522) 516055 E-Mail: LincsCoroner@lincoinshire.gov.uk Stuart P G Fisher HM Senior Coroner County of Lincolnshire 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 The incident date was 27" January 2015. The Incident Review Report was not received in this office until 10" August 2017. Why the delay? 2 §.13 recites an apology has been provided verbally and in writing. The families ask who made the apology. Also, when and where as they are adamant they have never received one. 3 PF confirmed on oath that none of the Action Plan referred to in the Appendices at 3 have been implemented. If not, in view of the Incident Date why not? Copy of the Incident Review Report is attached for ease. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or your organisation 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 29") 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. 4 Lindum Road, Lincoln, Lincolnshire, LN2 1NN TEL: (01522) 552500 FAX: (01522) 516055 E-Mail: LincsCoroner@lincolnshire.gov.uk Stuart P G Fisher HM Senior Coroner County of Lincolnshire COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ‘Ae | 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. Date: 4" December 2017 cud . PAUL S'COOPER = « «. occccstececalascessistisicercesediestoom rctredieemner ics oe H M ASSISTANT CORONER FOR THE COUNTY OF LINCOLNSHIRE 4 Lindum Road, Lincoln, Lincolnshire, LN2 1NN TEL: (01522) 552500 FAX: (01522) 516055 E-Mail: LincsCoroner@lincolnshire.gov.uk
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.
serene: IS @o@ United Lincolnshire Hospitals INHS| CARING YOU NHS Trust Office of the Medical Director Trust Headquarters Dr Neill Hepburn, Medical Director (GMC No 2855408) . ; — | Tel: 01522 573850 Lincoln pm A en Dr Richard Andrews, Associate Medical Director (GMC No 3172313) Lincoln Emel rs: 01522 573179 LN2 5QY Dr Gurdip Samra, Associate Medical Director (GMC No 3180655) Email: Tel: 01205 445338 : Tel: 01522 573850 Fax: 01522 573991 Dr Matthew Dolling, Director of Medical Education & Training Email: .Director.Education&Training@ulh.nhs.uk Tel: 01522 573846 PA to Medical Director: Kate Casburn Email: 28 January 2018 Mr Paul Cooper Assistant Coroner Lincolnshire [Via email] Re:- BREISLIN DOROTHY, Ref: INQ/4903 ‘ Dear Mr Cooper | write further to your Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mrs Breislin. , Matters of concern 1. The incident date was 27 January 2015. The incident review report was not received in this office until 10 August 2017. Why the delay? | can only apologise for the unacceptable delay in not only recognising that this was an SI! but for the delay in forwarding the final report to you. The Trust recognises that the SI process at that time was poor. We are working hard to clear our backlog of SI reports, which is being overseen by myself and the Director of Nursing and we are also implementing a new SI process. This incorporates training across the Trust on undertaking SI investigations. We currently have an Interim Director of Governance in post who is leading on this project and a new Risk Manager will be starting in February 2018. Whilst this is a work in progress, |-hope you will be assured that the Trust is striving towards a much improved SI process. 2. $13 recites an apology has been provided verbally and in writing. The family asks who made the apology. Also when and where as they are adamant they have never received one. This Duty of Candour section is what should have happened. | have no evidence that any verbal apology was made and indeed a written apology should have been done, but was not. Again, | can only apologise that what we should have done was at Mog, : Fe is MINDFUL 2 < EMPLOYER Chairman: Dean Fathers Chief Executive: Jan Sobieraj (Mr) say AaB not done. 3: BE contirmes on oath that none of the Action Plan referred to in the ‘ Appendices at 3 have been implemented. If not, in view of the incident date, why not? 7 The VTE Nurse Manager and the Consultant Haematologist met up in August 2017 to discuss the changes and these were agreed. This was to be discussed at the September 2017 Thrombosis Committee meeting but the meeting was cancelled as both the Chair and Vice Chair were unable to attend. Unfortunately, due to an oversight the matter was not put onto the November agenda. This was picked up in December 2017 when the form was sent io ii (Consultant Physician) to update the clerking proforma risk assessment. | understand that the updating clerking proforma was to go to print and be available for use in January 2018. | have been advised that the revised risk assessment will be sent to Stores to re-print on Monday 29 January 2018 and then be circulated to the Clinical teams. Yours sincerely Neill Hepburn Neill Hepburn mea mo FrcP (2855408) Medical Director Sige MINDFU Chairman: Dean Fathers EV/S FUL Chief Executive: Jan Sobieraj (Mr) < S EMPLOYER sy
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