Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0074, 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 | 2018-0074 |
| Deceased | William Abrahams |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| 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.
HM Senior Coroner ‘ Inner North London REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Simon Stevens Chief Executive NHS England . PO Box 16738, Redditch, B97 SPT CORONER lam: Assistant Coroner Sarah Bourke Inner North London ; Poplar Coroner’s Court 127 Poplar High Street London ; E140AE . 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 1 September 2017, Assistant Coroner Buckett commenced an investigation into the death of William John Abrahams who was born on 18 May 1936. The investigation concluded at the end of the inquest, which was conducted by me on 17 January 2018. The conclusion of the inquest was that Mr Abrahams died of natural causes. | recorded a medical cause of death of: 1a ruptured abdominal aortic aneurysm CIRCUMSTANCES OF THE DEATH Mr Abrahams presented to the A&E Department at the Royal London Hospital on 28 August 2017 with a 24-hour history of abdominal and back pain. He was found to have a ruptured abdominal aortic aneurysm. He underwent endovascular repair. The procedure was started under local anaesthetic with sedation but was then converted to general anaesthetic as Mr Abrahams’ heart rate, blood pressure and clotting status was difficult to maintain. Mr Abrahams remained unstable during the procedure. He was found to have intraperitoneal fluid as a result of the rupture of the aneurysmal sac into the peritoneum. It was decided that Mr Abrahams would not survive any further intervention. He died at the hospital that evening at 6.48 pm. 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) Mr Abrahams was not invited for screening to check whether he had an Abdominal Aortic Aneurysm, as he was over 65 at the time that the screening. programme \ was introduced. (2) Only about 20% of people that have a ruptured Abdominal Aortic Aneurysm survive (3) As Abdominal Aortic Aneurysms are asymptomatic until they begin to leak, the benefits of “opting in” to the screening programme may not be apparent to ‘patients. ACTION SHOULD BE TAKEN \n my opinion, action should be taken to prevent future deaths and | believe you 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 16 April 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. COPIES and PUBLICATION | have sent a copy of my report to the following: e HHJ Mark Lucraft QC, the Chief Coroner of England and Wales es davehters of Mr Abrahams e [have also sent it to EEE who may find it 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. Sarah Bourke Assistant Coroner
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.
Sarah Bourke Assistant Coroner Inner North London Poplar Coroner's Court 127 Poplar High Street London E14 0AE Dear Sarah NHS, VEARS England = as Professor Stephen Powis National Medical Director Skipton House 80 London Road SE1 6LH [SOAP 2018 Re: Regulation 28 Report to Prevent Future Deaths William following an inquest into the death of John Abrahams Thank you for your Regulation 28 Report (“Report”) dated 17 January 2018 concerning the death of William John Abrahams on 28 August 2017. | would like to express my deep condolences to Mr Abrahams’ family. The Report concludes William John Abrahams death was a result of natural causes with a medical cause of death recorded as a ruptured abdominal aortic aneurysm. Following the inquest you raised concerns in your Report to NHS England regarding — (1) Mr Abrahams was not invited for screening to check whether he had an Abdominal Aortic Aneurysm (“AAA”), as he was over 65 at the time that the screening programme was introduced. (2) Only about 20% of people that have a ruptured Abdominal Aortic Aneurysm survive. (3) As Abdominal Aortic Aneurysms are asymptomatic until they begin to leak, the benefits of ‘opting in’ to the screening programme may not be apparent to patients. With regards to point 1, men are currently invited to NHS Abdominal Aortic Aneurysm Screening Programme (“NAAASP’) in the year they are 65. The programme was introduced in England in 2009 on the recommendations of the UK National Screening Committee (“UKNSC”) following review of research evidence and data from existing local screening programmes against specific criteria’. This evidence showed a reduction in deaths from aneurysms when men were offered screening in their 65" year. Subsequently the UKNSC concluded that the ultrasound screening should be offered to men in their 65" year with men over 65 being able to self-refer or ‘opt in’ and request screening.” High quality care for all, now and for future generations All NHS screening programmes are implemented on the recommendations of the UK National Screening Committee (“UKNSC”) which oversees screening policy in the UK. Recommendations are made to initiate screening programmes that target a defined group of the population which has been identified as being at risk and would benefit most from the screening test. The North East London NAAASP began in April 2013. At this time Mr Abrahams was 81 years and would therefore not have received an invitation to have AAA screening. However he would have received screening had he asked for an appointment. When there is new evidence that brings current recommendations into question, the UKNSC has a set process for review of this new evidence including consideration of the eligible age of those invited.* The NAAASP is led and coordinated in England by Public Health England including the development of the national service specification, quality standards and national programme awareness campaigns and patient information and promote informed consent in men aged 65 and over. NHS England is responsible for commissioning the programme according to the national service specification. The specification reflects the recommendations and sets out the requirements for delivery of the screening programme. To address your concern as detailed at point 2, research shows that offering men ultrasound screening in their 65" year should reduce the rate of premature death from ruptured AAA by up to 50 per cent. In January 2016 the National AAA Screening Programme had screened over one million men in England and over 10,000 aneurysms had been detected that need monitoring or treatment. 2000 of these were large aneurysms, requiring urgent surgery.’ Men that are found to have an aneurysm during AAA screening are referred to specialist vascular hospital services for further assessment, monitoring and if required surgery to treat the aneurysm. Men with screen detected aneurysms will see a nurse specialist for health assessment and health improvement advice and will either be referred for treatment or monitored with regular screening through the surveillance programme. Their risk is increased by smoking, high blood pressure or through close family history. With regards to your concern at point 3, during 2012-13 the North East London AAASP Communications and Engagement Plan promoted the launch of the programme in April 2013. This was targeted at men aged 64 years and older, their families, friends and carers; as well as key programme partners in the area (e.g. GPs, care home workers, district nurses, religious organisations, voluntary sector) who may be able to support the screening service by encouraging patients/people they have caring responsibilities for or friends or neighbours who are eligible to take up screening. High quality care for all, now and for future generations Each local AAA screening programme coordinates screening for their population. GP Practices are contacted to notify them of men due to be invited to screening and to inform them that men over the age of 65 who have not been screened can contact the service and self-refer. Promotional materials are also provided to each GP practices for Staff, display in public areas to promote awareness and accessibility to the screening programme. GPs are sent result letters to highlight men who have not attended and are requested to encourage self-referral to the programme. Screening programme staff have attended GP forums, provided promotional events in public venues such as Sainsbury supermarkets to improve awareness of men aged 64 and over and the wider public. In 2018-19 NHS England London Region Public Health Commissioners will continue to support London AAA screening programme providers to ensure that programmes work to improve men’s awareness of their options to attend screening. A local quality standard implemented by NHS England London ensures that programmes record the numbers of men in each local Clinical Commissioning Group over 65 who Self-Refer to the screening programme. This is monitored by commissioners and informs screening programme communication strategies with the local population. In 2018-19 this will include: - Targeted work with GPs in areas of higher deprivation and potential inequalities in access - Working with other health providers to ‘sign post’ men aged 64 and older to the programme - Promotional media campaigns for GP surgeries/Pharmacies/Public Arenas - Community events - Working with patient groups and advocates Using social media advertising and development of programme website Thank you for bringing your concerns to my attention. | hope this response provides you with the assurance that NHS England is responding to the concerns raised and has taken appropriate action. Yours sincerely, Professor Stephen Powis. National Medical Director NHS England High quality care for all, now and for future generations
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