Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0388, written 20 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Sep 2017 |
|---|---|
| Reference | 2017-0388 |
| Deceased | Peter Cotter |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
for Milton Keynes
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Will Hancock, Chief Executive South Central
Ambulance Service
1
CORONER
I am Mr Tom Osborne, HM Senior Coroner for Milton Keynes.
2
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://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 2nd February 2017 I commenced an investigation into the death of Peter (Peirce) Cotter, aged
84. The investigation concluded at the end of the inquest on 22nd June 2017. The conclusion of
the inquest was the he died as the result of an accident.
4
5
CIRCUMSTANCES OF THE DEATH
The deceased suffered an un-witnessed fall at home on the 27th January 2017. He suffered a
head injury and a fractured hip. He underwent surgery for his hip on the 31st January and his
cause of death was reported to us as:
1a) Myocardial Infarction
1b) Ischaemic Heart Disease
2) Fractured Femur (operated)
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. –
During the course of the evidence it became apparent that Mrs Cotter had telephoned
emergency services on 27th January 2017 and reported that her husband had had a fall, hit his
head and hurt his hip.
My concern is that the clinical decision support software system did not appear to register that
Mr Carter had suffered a head injury. He was receiving anticoagulant drugs and even a minor
head injury could have had catastrophic results if the head injury was not recognised and
treated. I believe that there should be a review of the triage system to ensure that all head
injuries are recognised and treated as emergencies.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
15th November 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
• The family of Mr Cotter
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.
9
Dated 20th September 2017
Signature_________________________
Tom Osborne
Senior Coroner for Milton Keynes
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
2 responses 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.
1 Trevelyan Square Boar Lane Leeds LS1 6AE 0113 397 3614 Mr T Osborne HM Senior Coroner for Milton Keynes HM Coroner’s Office Civic Offices 1 Saxton Gate East Central Milton Keynes MK9 3EJ 20th November 2017 Dear Mr Osborne I am writing in response to a Section 28 ruling from HM Senior Coroner. This follows the tragic death of Peter Cotter who passed away on 31st January 2017. This was followed by an investigation and inquest which concluded on 22/6/2017. I am writing in my role as the Clinical Director for NHS Pathways, which is the clinical decision support software for the national NHS 111 service. I am , BA, MSc, MB ChB (Sheffield). HM Coroner has requested that NHS Pathways review its management of patients calling with head injury symptoms to ensure they receive the correct level of clinical response. For information I have provided below a short summary of the functions that NHS Pathways performs and the governance that underpins it. Function of NHS Pathways NHS Pathways is a programme providing the Clinical Decision Support System (CDSS) used in NHS 111 and half of English 999 services. This triage system supports the remote assessment of approximately 13 million calls per annum. The majority of these assessments are completed by trained call-handlers who refer the patient into suitable services based on the patient’s health needs at the time of the call. The system is hierarchical, meaning that life-threatening problems assessed at the start of the call trigger ambulance responses, progressing through to less urgent conditions which require a less urgent response (or disposition) in other settings. Governance of NHS Pathways The safety of the clinical triage process endpoints resulting from a 111 assessment using NHS Pathways is overseen by the National Clinical Governance Group; this is made up of representatives from the Royal Medical Colleges. Senior clinicians from the Colleges provide independent oversight and scrutiny of the CDSS. www.digital.nhs.uk enquiries@nhsdigital.nhs.uk Alongside this independent oversight, NHS Pathways ensures its clinical content and assessment protocols are consistent with the latest advice from respected bodies that provide evidence and guidance for medical practice in the UK. In particular we are consistent with the latest guidelines from NICE (National Institute for Health and Clinical Excellence) The UK Resuscitation Council The UK Sepsis Trust NHS Pathways Assessment of Head Injury Symptoms Having reviewed the case and the Coroner’s concerns I am in a position to reassure HM Coroner that NHS Pathways identifies and assesses head injuries through a detailed series of questions, and specifically identifies if callers are on anti-coagulant treatment. In this particular case we triaged the call via our head injury flow as an emergency and this resulted in an emergency department disposition via ambulance transport within 1 hour. I can further reassure HM Coroner the series of questions used in head injury assessment is consistent with the latest NICE guidelines (issued January 2014) on the triage and early management of head injury in infants, children and adults. The 1 hour emergency department disposition reached in this particular case is also consistent with the NICE guidelines. For reference this guidance can viewed at https://www.nice.org.uk/guidance/cg176 I am happy to answer any further enquiries from HM Coroner. Yours sincerely Clinical Director NHS Pathways NHS Digital 1 Trevelyan Square Boar Lane Leeds LS1 6AE
South Central Ambulance Service NHS Foundation Trust Northern House, PRIVATE AND CONFIDENTIAL 7 - 8 Talisman Business Centre, Mr Thomas Osborne, Talisman Road, HM Senior Coroner for Milton Keynes Bicester, HM Coroner's Office Oxfordshire, Civic Offices OX26 6HR 1 Saxon Gate East Central VB s ens Milton Keynes MK93EJ Our reference: PFD/NHSP — HI calls 6" September 2017 Dear Mr Osbourne Thank you for your recent letter regarding the prevention of future deaths (PFD) report issued following the inquest hearing into the sad death of Mr Peter Cotter. To confirm, your concerns are: ‘During the course of the evidence it became apparent that Mrs Cotter had telephoned emergency services on 27th January 2017 and reported that her husband had had a fall, hit his head and hurt his hip. My concern is that the clinical decision support software system did not appear to register that Mr Carter had suffered a head injury. He was receiving anticoagulant drugs and even a minor head _ injury could have had catastrophic results if the head injury was not recognised and treated. |_believe that there should be a review of the triage system to ensure that all head injuries are recognised and treated as emergencies’. To confirm the advice that you were given at the inquest hearing by Po our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves. Our EOC Clinical Assurance & Training Manager has notified NHS Digital through their reporting portal of your concerns and that the Trust has advised you to redirect the PFD report to them. Their Clinical Lead is Dr Anil Gill and their contact details are detailed below for you: Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 GHR. Call - 0300 303 5678 (9am to 5 pm Monday to Friday excluding bank holidays.) Email - enquiries@nhsdigital.nhs.uk Yours sincerely jth Will Hancock Chief Executive Officer Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR
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