Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0409, written 22 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 | 22 Nov 2017 |
|---|---|
| Reference | 2017-0409 |
| Deceased | Susan Smalley |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths |
| Organisation named | Gloucestershire Hospitals NHS Foundation Trust · North Bristol NHS Trust · South Western Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
H M Senior Coroner for Gloucestershire
Ms Katy Skerrett
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Ms Lee, Chief Executive of Gloucestershire Hospitals NHS Foundation Trust, Trust
Headquarters, Alexandra House, Cheltenham General Hospital, Sandford Road,
Cheltenham, Gloucestershire GL53 7AN
2. Mr Wenman, Chief Executive of South Western Ambulance Service NHS
Foundation Trust, Trust Headquarters, Abbey Court, Eagle Way, Exeter Devon EX2
7HY
CORONER
lam Katy Skerrett, Senior Coroner for Gloucestershire.
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.
INVESTIGATION and INQUEST
On the 5" September 2016 | commenced an investigation into the death of Susan Ann Smalley.
The investigation concluded at the end of the inquest on the 8" November 2017. The conclusion
of the inquest was a narrative conclusion. The medical cause of death was 1A massive fronto-
temporal parietal acute subdural haemorrhage with frontal contusions and occipital skull fracture.
CIRCUMSTANCES OF THE DEATH
On the 8" August 2016 at approximately 14.30 hours Susan Ann Smalley, “Susan” a 67 year old
lady suffered a witnessed fall at home. She fell backwards from standing height onto hard
ground. Her family rang emergency services at 14.46 hours. They made three further calls. The
rapid responder arrived on scene at 15.41 hours, nearly an hour after the initial call. At this time
Susan was fully conscious, had a laceration to the back of her head and was vomiting. The
paramedic requested emergency back up. The ambulance arrived at 16.52 hours, just over two
hours after the initial call. The delayed arrival of the ambulance was due to demand for the
services being higher than the resources available. No earlier opportunity to respond to the call
has subsequently been identified.
Susan was conveyed to the nearest A&E at Cheltennam General (“CG”). During this transfer her
right pupil became dilated and her Glasgow Coma Score ("GCS") decreased to 14. Susan
arrived at CG at 17.27. Soon thereafter she suffered some facial weakness. She was not
formally assessed by the Emergency Department (“ED”) Consultant and was not admitted to CG.
Instead the Consultant decided to transfer Susan to Gloucester Royal Hospital (“GRH’) on the
basis that it was unclear whether Susan had suffered a stroke or a head injury. If Susan had
been formally assessed at this time she would have undergone a CT examination which would
have identified the significant head injury she had suffered. Instead the injury remained
undiagnosed and Susan was transferred to GRH.
Susan arrived at GRH at 17.50 hours. Her GCS had significantly decreased at this time. Susan
experienced a tonic clonic seizure. The ED Consultant administered phenytoin, vitamin K,
octaplex, and requested a CT scan. The CT was reviewed at 19.45. It revealed a significant
head injury. Neurosurgical opinion was sought from Southmead Hospital ("SM"). They advised
urgent transfer to SM, and administration of saline and mannitol in addition to the medications
that had already been administered on arrival at GRH.
The urgent transfer by ambulance was requested at 19.46. Two follow up calls were made. The
transfer occurred at 21.11, 1 hour and 23 minutes after the initial request. The transfer was
delayed due to demand for resources being higher than the resources available. However 35
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ
Tel 01452 305661 | Fax 01452 412618
minutes of this delay could have been avoided.
Susan arrived at SM at approximately 22.20 hours. She was assessed, and due to the severity
of her injury it was advised that she was not fit for operative intervention due to the very high
likelinood of serious and permanent neurological disability. She was admitted to ICU. She was
reviewed the following day and there was no change in her presentation. Following discussion
with her family it was advised that active care was to be withdrawn, and palliative care
commenced. Susan continued to deteriorate and she passed away on the 42" August 2016.
If Susan had arrived at SM earlier it is probable that she would have been fit for operative
intervention. Furthermore it is probable that she would have survived surgery and had a good
functional outcome. Susan’s delayed arrival at SM was due to a number of factors, some of
which were avoidable.
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. —
1. The sufficiency of ambulance resources that have been allocated to meet demand in
the Gloucestershire area,
2. Whether clinicians, patients and paramedics are clear as to which hospital, either
Gloucester Royal Hospital or Cheltenham General hospital, should be treating the
patient.
3. When urgent emergency transfers are requested between hospitals, how they are
appropriately expedited.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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
4pm 17" January 2018. |, 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
| have sent.a copy of my report to the Chief Coroner and to the following Interested Persons
(1)
(2) Ms Young, Chief Executive, North Bristol NHS Trust, Southmead Hospital, Southmead
Road, Bristol BS10 5NB
| 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
Ms K Skerrett Coroner
Senior Coroner for Gloucestershire
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ
Tel 01452 305661 | Fax 01452 412618
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