Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0066, written 6 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2018 |
|---|---|
| Reference | 2018-0066 |
| Deceased | Ellie Clark |
| Coroner | Wendy James |
| Coroner area | Gwent |
| Category | Community health care and emergency services 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.
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. The Practice Manager Grange Clinic 34 Westfield Avenue Newport NP20 6EY 2. Ms Judith Paget Chief Executive Aneurin Bevan University Health Board St Cadoc’s Hospital Lodge Road Caerleon NP18 3XQ 1 CORONER | am Wendy Ann James, acting senior coroner, for the coroner area of Gwent 2 | 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. 3 | INVESTIGATION and INQUEST On 03/02/15 David Thomas Bowen commenced an investigation into the death of ELLIE MAY CLARK (dob 02/01/10). The investigation concluded at the end of the inquest on 26/02/18. The conclusion of the inquest was that Ellie May Clark died from natural causes where the opportunity to provide potentially lifesaving treatment was missed. The medical cause of death being: 1 (a) Bronchial Asthma 4 | CIRCUMSTANCES OF THE DEATH Ellie was a child with a history of severe asthma, who had been admitted to hospital on several occasions as a result of this condition. Ellie’s consultant had written to her doctor at Grange Clinic (“the surgery”), advising that she was at risk of another episode of severe/life threatening asthma. Suffering with a wheezy chest, Ellie attended an appointment with a doctor at the surgery on 22/01/15, where she was told her condition was not severe enough to be prescribed steroids, but she should continue using her asthma pumps and be brought back to the surgery should her condition deteriorate. On 26/01/15 Ellie became ill in school. Her mother Pontacted the surgery to request a home visit as Ellie was unable to walk, and she had no form of transport and was also caring for her 8 week old daughter. This request was refused, but Ellie was triaged by the on call doctor to assess if an e' appointment was necessary. Over an hour later, a reception te offer an emergency appointment 25 minutes later. immediately recognised she would struggle to make the appointment on time,but she was not offered an alternative appointment and was told not to be late. nd Ellie arrived at the surgery a few minutes late and the doctor refused to see Ellie ,as she was late ,without making any clinical assessment, without asking if the on call doctor could see her or without offering any advice on what should do if Ellie’s condition worsened. fas told to bring Ellie back the following day. returned home with Ellie, who then died later that evening. 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 could 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 lack of an effective and robust care plan. No one clinician was allocated to oversee the long-term management and care of Ellie’s medical condition. She was dealt with by three different doctors at the surgery within a period of 5 days leading up to her death. (2) Ellie was turned away from an emergency appointment for being late without any clinical assessment or safeguarding advice being given. (3) A delay in Ellie being triaged for an emergency appointment resulting in insufficient notice being given a to enable timely attendance at the appointment. 4) The lack of an effective and robust triage system. The receptionist who spoke with a. the telephone and the doctor who triaged Ellie were different to the receptions spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment. (5) A note that Ellie had severe/life threatening asthma was not placed on her medical notes in a prominent position. (6) Support staff did not feel they would be supported if they challenged a doctor's decision or sought a second opinion. 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 30/04/18.1,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 and to the following Interested Persons: Harding Evans solicitors, RadcliffesLeBrasseur solicitors and to the LOCAL SAFEGUARDING BOARD. | have also sent it to HEALTHCARE INSPECTORATE WALES 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 response by the Chief Coroner. 6" March 2018 | WWiure o. Acting Senior Coroner (Gwent)
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.
Q: GIG | swrda techyd Pri ojo ngurin Bean hf * NHS University Health Board Our ref: INQ/ABHB70455/DM Direct line 01633 431673 Date 19 April 2018 Ms W James H M Coroner r . 8 Coroner’s Office 23 ppR Victoria Chambers 11, Clytha Park Road Newport South Wales NP20 4PB Dear Mrs. James I am writing further to your correspondence issued on 6" March 2018, regarding the outcome of the inquest held on 26% February 2018 into the death of Ellie-May Clark on 26 January 2015. In accordance with paragraph 7, Schedule 5 of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, you request a response from the Health Board outlining its position and the actions taken to prevent similar occurrences through shared learning and its monitoring and assurance arrangements. I can confirm that the Health Board has duly noted your recommendations and ensured a formal review of the action plan which was developed and implemented in 2015 immediately following the Health Board’s own investigation undertaken by the former Clinical Director, Primary Care Division was completed. This has been conducted in liaison with the Grange Clinic practice. It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally. Pencadlys Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerltion Caerleon Casnewydd Newport De Cymru NP18 3XxQ South Wales NP18 3xQ Fidén: 01633 234234 Tel No: 01633 234234 Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd lechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board Mrs W James 19 April 2018 The recommended actions arising from this tragic event have now been formally reviewed with the Clinical Director for Quality and Patient Safety and the Quality and Patient Safety Manager for our Primary Care Division. The action plan has been updated to ensure it is reflective of its current state, acknowledges the improvements made and those further developments required to provide ongoing assurances. During the meeting held with Health Board representatives and the practice on 29 March 2018, there was representation from senior GP and partners, Practice manager, Practice Safeguarding lead, Receptionist and the Practice Nurse with specialist interest in asthma. The practice were able to confirm and provide evidence of completion of actions as outlined following completion of Health Board serious incident investigation and discussion was held regarding any further actions and developments that have arisen from this learning. I understand that the Practice will be writing to you separately to confirm their specific actions and evidence of implementation of the actions they have taken. The practice provided confirmation that the duty doctor responsible for triaging deals with this solely and does not take routine appointments. There was evidence of extensive work undertaken to ensure that all existing and new staff members are instructed in a standardised best practice approach and that the standard operating procedure is used by all. A red flag/alert system is now in place to ensure that any patient specific condition concerns will appear on screen to alert the GP during review/consultation. There has been a significant amount of work undertaken within the practice to address workplace culture issues to promote an open and transparent healthy workplace which is advocated and supported by all partners and practice staff The Health Board can confirm that those actions and request for assurances outlined in your correspondence have been implemented and continue to be the focus of cross divisional work with primary care and lead consultant paediatricians. I am advised by our Lead Consultant Paediatrician that the consultant leads for asthma have met to discuss Ellie May’s case and the Regulation 28 report. He confirms that the plan for the next 6 months includes: 1. An audit of documentation (as per the pathway) of asthma education at discharge. 2. An audit of PAAP (person’s asthma action plans) being given in clinic and at discharge. Mrs W James 19 April 2018 3. As part of the paediatric consultant’s regular commitment to asthma teaching the team provide teaching for peers and juniors around their responsibilities, where adverse outcomes in Gwent are shared in terms of lessons learned, and the need for PAAPs as part of current standards review. 4. The team acknowledge that the high risk children may not be seeing their GPs nor paediatric services, and the team liaise with our Emergency Department(ED) to identify those children who have attended ED for asthma exacerbation more than twice per year. 5. The team recommit to following up all children who have received more than steroids and nebulisers for at least one year and any child that has been to Intensive Care Unit to follow up until transition or exacerbation-free stepdown in preventer treatment down to step 2 or less. 6. If these two groups of patients don't attend then the team will reappoint with a highlighting of neglect, with a referral to safeguarding if they do not attend (DNA) a second time. Within Primary Care a programme of work in response to the national audit of asthma-related deaths has taken place led by respiratory pharmacists within the Neighbourhood Care Network clusters. This has led to the development of a community pharmacy Local Enhanced Service to identify those patients with review outstanding or who were overusing reliever medication. Support has been enlisted from the respiratory specialist nursing team to support promulgation of learning. Since the inquest was held further correspondence has been issued by the ABUHB Medical Director to all GP practices and paediatric consultants to ensure that those lessons learned following this sad case are acknowledged and shared by the GP community. I hope this response has addressed the recommendations outlined and provided reassurance that lessons have been and continue to be learned across the Health Board and the wider GP community. However, if you have any further questions or concerns, please do not hesitate to contact my office on 01633 431673 Yours sincerely ois tafet Judith Paget Prif Weithredwr/Chief Executive
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