Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0080, written 15 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 | 15 Mar 2018 |
|---|---|
| Reference | 2018-0080 |
| Deceased | Jean Griffiths |
| Coroner | Jennifer Leaming |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: 1. The Secretary of State for Health, Jeremy Hunt MP, House of Commons, London SW1A 0AA 1 CORONER I am Professor M Jennifer Leeming, HM Senior Coroner for the Coroner Area of Manchester West. 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 On the 27th of July 2017 I commenced an investigation into the death of Jean Griffiths aged 70 years. The investigation concluded at the end of the inquest on the 6th March 2018. The conclusion of the Inquest was:- Natural Death 4 CIRCUMSTANCES OF THE DEATH On the 15th July 2017 Jean Griffiths died at Salford Royal Hospital having displayed symptoms of Acute Interstitial Pneumonitis. Her oxygen lead was found to be disconnected at the time, but this did not contribute to her death. 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: 1. In the course of the Inquest I heard evidence from who is a consultant in Respiratory Medicine at Salford Royal Foundation NHS Trust. referred in his evidence to the British Thoracic Society’s Emergency Oxygen Audit Report relating to a National Audit Period between the 15th August and the 1st November 2015. 2. stated that the Audit Report revealed a threat to patient safety due to poor prescribing practice in relation to the prescription of oxygen. 1 3. A key finding of the report was that 42.5% of patients receiving supplementary oxygen had no valid prescription. Without a valid prescription which includes a target range, stated that there was a danger that patients might be given too little oxygen or too much oxygen and thus be placed at risk of increased mortality. 4. A copy of the relevant Audit Report is attached. 5. evidence was that the pace of changing this poor prescribing practice needed to increase. 6. Although there was no evidence that Jean Griffiths’ lack of oxygen prescription was in any way causative of or contributory to her death nevertheless this report is submitted with a view to preventing the deaths of other patients who might be at risk. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you 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, namely by 10th May 2017. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. The Chief Executive, Salford Royal Hospital 2. 3. (husband) 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. Dated Signed 15th March 2018 M Jennifer Leeming, HM Senior Coroner 2
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.
a Department of Health Your reference: MJL/YD/104-18 Our reference: PFD 1125206 Professor M Jennifer Leeming HM Senior Coroner, Manchester West HM Coroner’s Court Paderborn House Howell Croft North Bolton BL1 1QY \\"May 2018 Door Kesfassor (gominp, Thank you for your letter of 19 March to the Secretary of State for Health and Social Care about the death of Mrs Jean Griffiths. I am responding as Minister with responsibility for patient safety. I was very saddened to read of the circumstances surrounding Mrs Griffith’s death. Please pass my condolences to her family and loved ones. | appreciate this must be a difficult time for them. Your Report raises a matter of concern in relation to oxygen prescribing practice in the NHS. Although I note there was no evidence that lack of an oxygen prescription in Mrs Griffith’s case was in any way causative of, or contributory to, her death, I am grateful to you for raising the concerns given in evidence at the Inquest that this is an area of patient safety risk. I have noted carefully the comments in your Report and the findings of the 2015 British Thoracic Society national emergency oxygen audit report. While it is encouraging that there has been a steady rise in the number of patients with a prescription, from 32 per cent in 2008 to 57.5 per cent in 2015, I appreciate the importance of making further progress to improve patient safety and reduce the risk of increased mortality. I am advised that the British Thoracic Society (BTS) updated its 2008 guideline for emergency oxygen use in adult patients in 2017', broadening its remit from emergency oxygen use to most other oxygen use in healthcare settings, as well as short term oxygen use by healthcare professionals outside healthcare settings. I am further advised that the guidance is supported by increasing evidence of its effectiveness in improving patient outcomes and reducing avoidable deaths. The guidance is widely endorsed by professional bodies, societies and colleges and forms an important resource for ensuring patient safety in the use of oxygen. In terms of disseminating best practice and use of the BTS guideline, I understand the BTS has taken action to establish a network of Oxygen Champions within all hospitals, has produced e-learning modules and learning resources for ambulance services, and importantly, continues to undertake clinical audits. I commend the excellent work done by the BTS in this area and encourage that to continue in partnership with the relevant Royal College’s and societies. To see what further action might be taken in this area, my officials have sought advice from the National Institute for Health and Clinical Excellence (NICE). NICE guideline CG101 Chronic obstructive pulmonary disease’ includes a section on oxygen therapy, which includes recommendations regarding appropriate patient assessment. The guideline is in the process of being partially updated and oxygen prescribing is one of the areas included in the update. While the focus of the update has been on safety (regarding the risk of explosions), NICE considers that a tightening of prescribing practice in this area is appropriate and will bring this to the attention of the guideline developers. The updated draft guidance is currently expected to go out for consultation with stakeholders in the summer. I am informed that the stakeholders include the BTS as well as relevant Royal Colleges. The BTS and other stakeholder organisations will have the opportunity to participate in the development of the guideline, and to comment on the draft guidance when it goes out for consultation in the summer. This provides potential for a further opportunity to ensure that guidance on oxygen prescribing reaches healthcare professionals. " https:// www. brit-thoracic.org.uk/standards-of-care/guidelines/bts-guideline-for-emergency-oxygen-use-in- adult-patients/ > https:// www.nice.org.uk/guidance/cg101 a Department of Health I hope that you find this information helpful. Thank you for bringing the circumstances of Mrs Griffith’s death to my attention.
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