Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0355, written 28 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Nov 2017 |
|---|---|
| Reference | 2017-0355 |
| Deceased | John Lea |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Acute Hospitals 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: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORTTO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Pennine Acute Hospitals NHS Trust CORONER I am Ms L Hashmi, Area Coroner for the Coroner area of Manchester North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroners and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST 1gth On the June 2017 I commenced an investigation into the death of John Lea, concluding by way of 217h inquest on the November 2017. 4 CIRCUMSTANCES OF DEATH On the 7th June 2017 Mr Lea was admitted to hospital, upon the referral ofhis GP, forfurther management of his heart failure. He had a numberofpre-existing co-morbidities, including stroke, peripheral vasculardisease, chronic obstructive pulmonary disease and chronic kidney failure. Treatment for heart failure was instigated and he appeared to respond well. At around 23:30 on the 1th1 June 2017, the ‘bay tagging’ nurse left the bay in orderto assist in another part ofthe ward. She could not see her bay from where she was, had not asked another to monitor the bay in her absence and upon her return, did not notice that Mr Lea was no longer in his bed. Leaving the baywithoutasking another nurseto observewas a breach ofpolicy. Mr Lea was found on the floor in a collapsed state, on the opposite side ofthe bay, at around 23:40. The emergency buzzer was activated and a crash call put out. Basic life support was commenced. Despite best attempts at resuscitation, the fact ofMr Lea’s death was confirmed at 00:04 on the 12th June 2017 at the Royal Oldham Hospital. It was not possible to say on the evidence heard whether earlier discovery/intervention would have materially altered the outcome. An internal investigation by the Trust identified a significant number oferrors and omissions (some ofwhich amounted to gross failingsto provide basic care) howevernonewere causally linked to Mr Lea’s death, Given the evidence overall, it is more likely than not that Mr Lea suffered a collapse as a result of a sudden cardiac- related event. conclusion natural causes — 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 reportto you. The MATTERS OF CONCERN are as follows: 1. In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess. 2. Poor communication between the nursing team, with particular reference to ‘bay tagging’. 3. Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased). 4. No escalation when the on call doctor failed to attend following a marked change in the deceased’s oxygen saturations. a 5. bo I u n t co b r y re t c h t e ly p c re a v lc io u u la s te e d arl N y E w W ar S ing sc s o c r o es re . to T o h l e (E N W E S W ), S y w et a m s i d st e a s k ig es ne w d ith to re a g d a d r r d es to s s m co is r t e ak c e a s lcu b l r a o t u io g n h s t continue. 6. Failure to adhere to Trust policy/protocol — prevention offalls, patient observation. 7. Insufficient progress with regard to the NAAS rating for the ward in question (initial assessment a year ago ‘red’, more recent assessment ‘high amber’). 6 ACTION SHOULD BE TAKEN h In av m e y th o e pi p n o io w n er ac to tio ta n ke sh s o u u c l h d a b c e ti t o a n k . en to prevent future deaths and I believe each of you respectively 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 23 day of January 2018. I, the Coroner, may extend the period. Y ac o ti u o r n. res O p t o h n er s w e is m e u y s o t u co m n u ta s i t n ex d p e l t a a i i n ls w o h f y a n c o tio a n cti t o a n ke is n p o r r op p o r s o e p d o . sed to be taken, setting out the timetable for 8 COPIES and PUBLICATION I have sent a copy ofmy report to the ChiefCoroner and to the following Interested Persons namely: . The deceased’s family . CQC (Per M0U) I am also undera duty to send the ChiefCoronera copy ofyour response. T c re o h p p e r y e C s o e h f n ie t t f a h t C i i s o o n r r s o ep n to o er r m t m e to ay th a e p n u y c b o l r i p s o e h n rs e e o r i n t a h t e w r th h o e o r t b i h m o e t e h b o i e f n li y a e o v u c e r o s m re m p s l p a e y o te n f s i o e n r , d r a e i b t d o a u u c s t t e e t f d h u e l o r r o e r s l u e o m a f s m e in a o t r e r y r t e h f s r e t o . m pu . Y b H l o i e c u a m ti m o a n a y y o s f e m n y d a o k u e a r response by the ChiefCoroner. Date: 2th8 November2018 Signed:
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