Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0017, written 16 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2018 |
|---|---|
| Reference | 2018-0017 |
| Deceased | Keith Harwood |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & the Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust · Lancashire Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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:
Acting Chief Executive
Blackpool Teaching Hospitals NHS Foundation Trust
Blackpool Victoria Hospital
Whinney Heys Rd
Blackpool
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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.
3
INVESTIGATION and INQUEST
The death of Mr Keith James Harwood was reported to me on 4th January 2017. An
investigation was commenced and in due course an inquest held at the Town Hall,
Blackpool on 10th & 11th January 2018.
The medical cause of death was recorded as follows:
1a sepsis due to sub-phrenic abscess and bronchopneumonia
b necrosis around PEG tube feeding site
c cerebral atrophy due to hypoxic brain injury following aortic valve
replacement
The inquest concluded by way of a Narrative conclusion as follows:
Diagnosed with Parkinson’s disease in 2000 Keith Harwood underwent elective
cardiac surgery on 23rd July 2014. Nine days post - operatively he went into
cardiac arrest whilst being treated on ward 38 (Blackpool Victoria Hospital) on 2nd
August 2014. A re-sternotomy procedure was performed on the ward but it was
later confirmed that he had suffered a significant hypoxic brain injury the impact
of which was he remained in a persistent vegetative state. Nourishment was
thereafter provided by a PEG tube. In August 2016 he was referred for a review of
the PEG (Percutaneous endoscopic gastrostomy) tube site. The site was regularly
reviewed over subsequent months. In October 2016 Buried Bumper Syndrome
was confirmed. At a time when consideration was being given as to how to
address this syndrome he was admitted to hospital on 17th December 2016 with a
suspected pneumonia. Whilst in hospital his condition deteriorated and he died
on 29th December 2016. A subsequent post mortem examination identified that he
died as a result of the combined effects of bronchopneumonia and of a sub-
phrenic abscess which had developed during the week prior to his death.
1
4
CIRCUMSTANCES OF THE DEATH
In addition to the Narrative conclusion above please note the following:
The Deceased had suffered with Parkinson’s disease for approximately 16 years by the
time he was admitted for elective cardiac surgery in July 2014. At the inquest the court
heard evidence how his Wife – by now extremely knowledgeable about her Husband’s
condition and its treatment - had been asked to attend pre-theatre to advise the treating
team about the management of his Parkinson’s medication. Post – surgery there was
some confusion about the administration of his medication, and when some days later
he began to demonstrate extreme bouts of dyskinesia this was not recognised by
medical staff and
needed to explain his symptoms to them.
When Mr Harwood then suffered a cardiac arrest and resultant hypoxic brain damage
his family expressed the view that his cardiac arrest was connected to those earlier
bouts of dyskinesia which in turn were connected to the earlier confusion about how his
Parkinson’s medication had been administered. As it transpired, such a causative
connection was not accepted by cardiac experts instructed by the court and the hospital
Trust. Nevertheless, it was clear that prior to, during and after his cardiac surgery the
medical team had not fully appreciated the potential significance of his Parkinson’s
disease and that it may have been necessary to seek specialist input and advice both
prior to and potentially throughout his admission. (Some limited training of staff had
taken place as regards the use of a Apomorphine pump).
Indeed the hospital Trust’s own Sudden Untoward Incident Review [April 2015]
recognised this to some extent commenting as follows:
There was late involvement of the community Parkinson’s team.
The severity of his Parkinson’s disease was not fully appreciated at the pre-
admission clinic
There was no neurology input post –operatively.
That review recognised the need for improved preparation and communication prior to
hospital admission in respect of a patient’s complex medical needs.
The review acknowledged that the potential significance of Mr Harwood’s condition had
not been fully recognised. All Consultants and cardio thoracic staff were therefore
informed of the need to notify the Clinical Matron in the event that it became apparent at
a pre-admission clinic that someone with complex needs may be about to be admitted to
hospital. Further, the Trust introduced a policy document specific to the acute
management of inpatients with Parkinson’s disease and the need for early involvement
of the “Parkinson’s specialist team” but unfortunately it remains unclear as to what the
Parkinson’s specialist team is comprised of , the level of assistance that team may be
able to provide, and from where and how quickly neurology input may be obtained and I
therefore felt that despite the introduction of this policy, the Trust’s response to the
events surrounding Mr Harwood’s hospital admission in the summer of 2014 has not
eradicated the risks of future deaths. For example, the inquest received some evidence
about that policy document during the course of the inquest from one of the co-authors
of the Sudden Untoward Incident Review, I was left far from convinced that hospital
personnel have been equipped with the knowledge and the information to know who to
contact and how to source the necessary assistance in the event that a patient with
complex needs should attend the hospital for surgery in the future, be it Parkinson’s
disease or some other complex illness and particularly in the event that specialist advice
needs to be sourced from a different location.
At the Blackpool Teaching Hospitals NHS Foundation Trust there is no specialist
neurological input available on site. It was unclear at the inquest from where such
neurology input would be sourced if required.
2
Further, the need for such advice may arise relatively quickly if the need for such advice
has not been appreciated fully at the pre-admission stage because (as a consultant from
the hospital Trust in Blackpool informed the court) the Trust does perform a large
number of procedures on the day of admission. Mr Harwood’s cardiac surgery was
carried out on the same day as his admission. This was an issue commented upon by
an independent cardiac surgeon who felt that “Mr Harwood was quite a complex patient
who underwent relatively major cardiac surgery. His complex medical problems with his
Parkinson’s disease did not make him the ideal candidate for same day admission.” That
this may allow little time for medical staff to source any expertise from elsewhere prior to
surgical procedures taking place adds to the need for greater clarity about where to go
for advice if dealing with a patient who’s condition is complex and unfamiliar to the
medical professionals dealing with the patient.
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:
When giving consideration to writing a report to prevent future deaths Coroners are not
limited to deaths which are felt to have been contributed to by the issue causing the
Coroner some concern. As stated above the expert opinion received at the inquest and
accepted by the court was that a connection between Mr Harwood’s Parkinson’s disease
and his cardiac arrest could not be established.
However, I have concerns that despite the introduction of a Trust policy, the evidence
heard at this inquest suggests that medical professionals may find themselves in a
position whereby, as with events surrounding Mr Harwood’s care, they are faced with an
unfamiliar condition and without being able to source the requisite (possibly urgent)
specialist advice.
The co-author of the SUI review was unsure about what assistance would be available
particularly in relation to neurology input.
I remain therefore concerned that a family such as Mr Harwood’s may find themselves
being asked to educate medical staff about the potential implications of a certain
condition..
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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,
3
namely by 13th March 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
Harwood family
Lancashire Teaching Hospitals NHS Foundation Trust
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.
8
9
A.A.Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 16th January 2018
4
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.
NHS Blackpool Teaching Hospitals NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool FY3 8NR Telephone: 01253 956993 Email: dr.odonnell@bfwhospitals.nhs.uk 29 January 2018 Mr Alan Wilson Senior Coroner for Blackpool & the Fylde Municipal Buildings Corporation Street Blackpool FY1 1GB Dear Mr Wilson Re: Regulation 28 Report to Prevent Future Deaths — Mr Keith James Harwood | write in response to your Regulation 28 report to prevent future deaths in respect of Mr Keith Harwood. The events surrounding Mr Harwood’s care date from July 2014 and relate to the management of his Parkinson’s disease. At that time Neurological advice for patients in the Trust suffering from Parkinson’s disease was provided by a visiting Consultant Neurologist from Lancashire Teaching Hospitals NHS Foundation Trust. In August 2016 the Trust appointed a Consultant Physician in Care of the Elderly who has specific expertise and interest in the management of Parkinson’s disease. In December 2016 he co-authored a procedure for the acute management of in-patients with Parkinson's disease and you have had sight of this. Notwithstanding the uncertainty expressed to you by the co-author of the SUI review about what assistance would be available to patients, section 2 on page 3 of the procedure explicitly states the importance of early involvement of the Parkinson’s Specialist Team and contact details are provided in section 3.8 on page 14. These details include contact numbers for the Parkinson's Disease Nurse Specialist, the Consultant Physician and helplines, one of which is specific to the management of patients with Apomorphine infusion. That advice and training from the pharmaceutical company is readily available at immediate notice if required. | shall as a consequence of your communication be issuing an internal alert within the Trust reminding all staff of the importance of timely management of patients with Parkinson's disease, timely referral to the Parkinson's Specialist Team and the availability of the procedure document on the Trust intranet. Yours sincerely WADewnell. PROFESSOR MARK O’DONNELL MEDICAL DIRECTOR = RESEARCH MATTERS AND SAVES LIVES - TODAY'S RESEARCH IS TOMORROW'S CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. & Ny INVESTORS © disability Health & care | Chairman: Mr lan Johnson M.A., LL.M. 4 YIN PEOPLE Gold |f§6@confident| | Siz youcan trust | Chief Executive: Wendy Swift COMMITTED i
See every Prevention of Future Deaths report matching Blackpool Teaching Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.