Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0040, written 8 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Feb 2018 |
|---|---|
| Reference | 2018-0040 |
| Deceased | Howard Winter |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| 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.
ANNEX A 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. Chief Executive of Cwm Taff University Health Board CORONER | am Graeme Hughes, Assistant Coroner, for the coroner area of South Wales Central Area. 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 21* September 2017 | commenced an investigation into the death of Howard Winter aged 85. The investigation concluded at the end of an inquest on 1* February 2018. The medical cause of death was 1a. Hospital Acquired Pneumonia, 1b C5-6 vertebral fracture with cord injury, alongside subdural bleeding in the setting of a person with ankylosing spondylitis, 1¢ Recurrent Falls & 2. Vascular Dementia. The conclusion of the inquest was Accidental Death. CIRCUMSTANCES OF THE DEATH The deceased was a resident at the Daffodils CH, Merthyr Tydfil. He suffered from vascular dementia & had frequent falls. On 23.8.17 he fell in his room, sustained a serious head injury & was taken to PCH, Merthyr Tydfil. On 11.9.17 he was diagnosed with a fractured spine. He developed pneumonia & died there on 16.9.17 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 Mr Winter attended at A & E on 23 & 26.8.17, he was diagnosed with a subdural haematoma following a CT scan head. It was not until after a CT scan of his spine was undertaken on 11.9.17 that he was diagnosed with a cervical spine fracture. The question arose as to whether, & following his initial presentation on 23.9.17 & admission on 26.8.17 there was any evidence of symptoms of neck pain which could have given rise to earlier investigations into, & possible earlier diagnosis of the cervical spine fracture. ae o- evidence at the Inquest that on the 26.8.17 an auxiliary nurse had recorded in the nursing notes — “pain in neck/back — unable to score”. There was no evidence — written or otherwise, to demonstrate an escalation of this finding to a doctor for re-assessment, investigation & diagnosis. levidence to the Inquest was that this ought to have occurred. Whilst this apparent absence of escalation may not necessarily have affected the outcome for Mr Winter, were it to be repeated now, or in the future, the outcome for the patient involved could be potentially causative of/contribute towards death/adverse i outcome. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 5" 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 | have sent a copy of my report to the Chief Coroner, the family and the Minister of Health Welsh Government Assembly who may find it useful or of interest. | 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 re: e by the Chief Coroner. 8" February 2018 SIGNED: N
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.
Your Ref/eich cyf: Our Ref/ein cyf: KA/LB 4 GIG | swrdd techyd Prifysgol Date/dydaiad: 19" March 2018 Gr Cwm Taf Tel/ffén: 01443 744921 N HS Fax/FFacs: 01443 744889 University Health Board Email/ebost: Kamal.asaad@wales.nhs.uk Dept/adran: Executive Private & Confidential Mr AR Barkley Senior Coroner for South Wales Central Rock Grounds First Floor Aberdare CF44 7AE Dear Mr Barkley RE: Regulation 28 for Howard Winter Thank you for the correspondance in relation to the above Regulation 28 received on 14" February 2018, which was also sent to the Health Board CEO Mrs Allison Williams. Please note that I have discussed the content of your letter with both the CEO and the Director of Nursing. In relation to improvement work being undertaken within Cwm Taf University Health Board regarding NEWS I wish to assure you that the following work has taken place: 1. Two audits have been undertaken across the Health Board to measure how the NEWS scores are completed and escalated. 2. We have a University Health Board Clinical Lead for the RRAILS (Rapid Response to Acute illness Learning Set) who is a Consultant Anaesthetist and also the National Lead overseeing this important piece of work. The audit has identified the need for further education and training as well as raising awareness amongst nursing and medical staff in relation to accurate documentation and escalation. The audit has also identified priority clinical areas for improvement work which will be progressed. Monitoring of the improvement work is undertaken via the quarterly quality report to the Quality & Risk Safety Committee. I hope that I have provided assurance to you that your concerns are being dealt with in the University Health Board as part of our ongoing Quality Delivery Plan. Kind Regards ZU MAR 2018 Return Address: Cwm Taf University Health Board, Headquarters, Navigatio 4SN Chair / Cadeirydd; Professor Marcus Longley Chief Executive / Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board is the operational name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gwelthredo! Bwrdd lechyd Prifysgol Cwm Taf Vownal Asan. Mr Kamal Asaad Medical Director Cwm Taf University Health Board Cc. Mrs Allison Williams, CEO, Cwm Taf UHB Mrs Lynda Williams, Director of Nursing & Midwifery Services, Cwm Taf UHB Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF4! 4SN : Chair / Cadeirydd; Professor Marcus Longley Chief Executive / Prif Weithredydd: Mrs A Williams Cwm Taf University Health Board is the operational name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gweithredo! Bwrdd lechyd Prifysgol Cwm Taf
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