Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0056, written 22 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 | 22 Feb 2018 |
|---|---|
| Reference | 2018-0056 |
| Deceased | James Quinton |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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.
Ms N J Mundy Senior Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr Sewa Singh Medical Director, Doncaster Royal Infirmary, Armthorpe Road, Doncaster CORONER lam Ms N J Mundy, Senior Coroner for South Yorkshire (East District) 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. http:/Awww. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 25/03/2017 | commenced an investigation into the death of James Robert Quinton, 42 . The investigation concluded at the end of the inquest on 30 January 2018. The conclusion of the inquest was a Narrative conclusion: James Robert Quinton collapsed on 14 March 2017 due to a combination of a ruptured spleen and methadone and heroin ingestion. Mr Quinton failed to respond to extensive resuscitation and supportive measures and he died in the Doncaster Royal Infirmary later that day. The cause of death was 1a. Splenic rupture and combined morphine and methadone toxicity 2. Rivoroxaban therapy CIRCUMSTANCES OF THE DEATH James Quinton had a known history of chronic drug and alcohol abuse. His partner had been in a relationship with him for 12 years and has no knowledge of him having ever had any employment. He had a medical history of alcoholic liver disease, intravenous drug misuse, hepatitis C, epilepsy, previous DVT, on rivaroxaban, schizophrenia. He was admitted to DRI A&E at 02:30 hrs with a presenting history of 1 week vomiting blood, 1 day abdominal pain. He had been found unresponsive on the bathroom floor collapsed. On admission he was unresponsive - Investigations commenced -Bloods were taken - INR 3 - given vitamin K to reverse. Acidotic PH6.8, lactate greater than 20. 03:15 hrs cardiac arrest - arrest call - ALS - adrenaline, noradrenaline given. Femoral line put in place, sodium bicarbonate and glucose given. ROSC GCS low - pupils remained fixed and dilated. CT abdomen results - query splenic bleed. He was transferred to ICU - reviewed and discussions held with NOK. Decision due to significant Co-morbidities and poor status it was the opinion of the physicians that he would gain no benefit from any surgical intervention. Active treatment was withdrawn and he died on 15/03 at 14:26 hrs. | have spoken to Kelly Coates (partner) and she informs that the last time the deceased used illicit drugs was on the morning of Monday 13th March (heroin). She states that over the previous 7 days he had been unwell periodically vomiting. 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. — Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 (1) During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring. Clearly poor record keeping has significant implications for patients. (2) Furthermore, during the course of the resuscitation a decision was made for Mr Quinton to be given 4 mgs of Noradreneline. This was to be given as an infusion. Unfortunately, this was actually given as a 4 mg iv bolus. Although the records suggest this did not have a detrimental effect on Mr Quinton (his blood pressure had been exceptionally low) this clearly could be highly significant for other patients. It also raises the question of other patients being given either the wrong drug or the wrong amount of drug or the wrong method of administration when the procedure for drugs to be prescribed in this scenario is on a verbal basis only. It would seem sensible to have some checking procedure by the person administering the drugs checking with the person who had prescribed it to make sure their understanding is correct. From the evidence | heard it seems there are no such procedures in place. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Dr Sewa Singh 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 19 April 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 senta = of m =“ to the Chief Coroner and to the following Interested Persons | 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 pyblication of your response by the Chief Coroner. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
hi’ Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Doncaster Royal Infirmary Armthorpe Road, Doncaster South Yorkshire DN2 5LT Medical Director’s Office Tel: 01302 366666 Fax: 01302 320098 Mrs Singh, Medical Dir Minicom: 01302 553140 (only for people who are deaf} 5 April 2018 Ms N J Mundy Senior Coroner, South Yorkshire (East District) Coroner’s Court and Office Crown Court College Road Doncaster DN1i 3HS Dear Ms Mundy Re: James Robert Quinton (Deceased) DOB: 03.01.1975 — DOD: 14.03.2017 | write in response to Regulation 28 Report ‘Prevention of Future Deaths’ dated 22 February 2018 sent to the Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and for which I thank you. | note your concerns as follows; 1. Poor quality nursing notes and lack of information on the observation chart making it difficult for reviewing consultants to get a clear picture of events that had been occurring. 2. In the course of resuscitation a drug which was supposed to be given by infusion was given as a bolus raising the question of the wrong drug or the wrong amount of drug of the. wrong method of administration occurring when drugs are prescribed in such a scenario on a verbal basis only. | have been assisted by FY Matron, Emergency Department (ED) and YY ED Governance Lead in constructing this response. | would respond as follows; 1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department. The Matron has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the resuscitation. The Emergency Department is also in the process of obtaining an update of the software on the current monitors in order to allow automatic printing of the observations in the course of the procedure. | am informed — a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end of April to look at systems and processes for working together within the Resus area. | understand that the IV Drugs Administration Policy has also been sent to all qualified staff in the emergency department. Matron Sidwell has also advised me_ that the clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status I take this opportunity to enclose for your awareness the relevant policies which are available on the Trust Intranet. Safe and Secure Handling of Medicines Policy PAT/MM1a Safe and Secure Handling of Medicines Policy — Controlled Drugs PAT/MM1b Injectable Medicines Policy PAT/MM5 | trust that the contents of this letter will reassure you that the Trust has taken steps to minimise the risk of a recurrence of the events outlined in the PFDR document. Please do not hesitate to revert back to me should you feel that there are any outstanding issues. Yours sincerely thee Deputy Medical Director - Clinical Standards Ce 1 Mr Richard Parker, Chief Executive
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