Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0086, written 22 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 | 22 Mar 2018 |
|---|---|
| Reference | 2018-0086 |
| Deceased | Kenneth Longley |
| Coroner | Rachel Galloway |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Medical Director, Wythenshawe Hospi CORONER tam Rachel Galloway, assistant coroner, for the coroner area of South Manchester 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 12" September 2017 an investigation was commenced into the death of Kenneth Longley .Subsequently an inquest was opened on the 19" September 2017 and concluded on the 15" February 2018. The medical cause of death was found to be: 1a massive spontaneous upper gastrointestinal haemorrhage 1b. Anticoagulation therapy for myocardial infarction || Myocardial Infarction, Aortic stenosis CIRCUMSTANCES OF THE DEATH Mr Longley died on the 9/9/17. On the 27" April 2017 he suffered a collapse and attended Wythenshawe hospital. He was discharged with an echocardiogram to be undertaken. The echocardiogram was carried out on the 16" May 2017, which confirmed severe aortic stenosis. IE cferred Mr Longley back to his GP in order that the GP might refer Mr Longley to the Cardiology Department at his local hospital. The said letter was only signed on the 7” August 2017 and was received by the GP surgery (who then took no further action) on the 7 August 2017. A separate Regulation 28 Report has been sent to the GP surgery. The letter was therefore sent out nearly 3 months following the original echocardiogram in May 2017. In September 2017 Mr Longley suffered a further collapse and was admitted to the Acute Coronary Unit at Tameside Hospital. Mr Longley was found to have acute coronary syndrome as well as severe aortic stenosis. He was given anticoagulation therapy to treat the acute coronary syndrome (as there had been a rupture of the lining of the artery which had caused a partial blockage). Unfortunately, the necessary anticoagulation treatment led to an upper gastrointestinal bleed and Mr Longley’s death at Tameside Hospital on the 9" September 2017. 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. — The letter from Doctor 2 Mr Longley’s GP was sent out on the 7" August 2017, nearly 3 months following the echocardiogram on the 16"" May 2017. This appears to be a significant delay EE explained in evidence that there had been a delay in obtaining the medical records needed Lc write the report to the GP but the cause of that delay was not known. It was not clear why the letter was only written on the 29" July 2017 and then not sent out until the 7" August 2017. Mr Longley had severe aortic stenosis. The evidence suggested that cardiac surgery would have been offered to Mr Longley and would have taken place within 3-6 months. In this case, it was not possible to determine whether the outcome would have been different for Mr Longley had the letter been sent out in a timely fashion. The concern is that there is a risk of future death if there is a delay in sending out similar letters in the future. ACTION SHOULD BE TAKEN In 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 17" May 2018. The assistant 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 namely the family of Mr Longley, who may find it useful or of interest. lam 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. Rachel Galloway HM Assistant Coroner 22/03/2018 tv REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: : Partners at the Cornerstone Family Practice, Graham Street, Beswick, Manchester M11 3AA CORONER | am Rachel Galloway, assistant coroner, for the coroner area of South Manchester 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 12" September 2017 an investigation was commenced into the death of Kenneth Longley .Subsequently an inquest was opened on the 19" September 2017 and concluded on the 15" February 2018. The medical cause of death was found to be: 1a massive spontaneous upper gastrointestinal haemorrhage 1b. Anticoagulation therapy for myocardial infarction Il Myocardial Infarction, Aortic stenosis CIRCUMSTANCES OF THE DEATH Mr Longley died on the 9/9/17. On the 27" Aprit 2017 he suffered a collapse and attended Wythenshawe hospital. He was discharged with an echocardiogram to | be undertaken. The echocardiogr ied out on the 16" May 2017, which | confirmed severe aortic stenosis. aii: Mr Longley back to his GP in order that the GP might refer Mr Longley to the Cardiology Department at his local hospital. The said letter was only signed on the 7" August 2017 and was received by the GP surgery on the 7"" August 2017. A separate Regulation 28 Report has been sent to Wythenshawe Hospital. a a in evidence that, whilst the surgery had received the letter Tol on the 7" August 2017, it had been allocated to a GP to action who had then not picked it up until October 2017 (after Mr Longley’s death). In September 2017 Mr Longley suffered a further collapse and was admitted to the Acute Coronary Unit at Tameside Hospital. Mr Longley was found to have acute coronary syndrome as well as severe aortic stenosis. He was given anticoagulation therapy to treat the acute coronary syndrome (as there had been a rupture of the lining of the artery which had caused a partial blockage). Unfortunately, the necessary anticoagulation treatment led to an upper gastrointestinal bleed and Mr Longley’s death at Tameside Hospital on the 9" September 2017. 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. — The letter from a. which was received by the GP surgery on the 7" August 2017, referred to an echocardiogram on the 16" May 2017 which confirmed severe aortic stenosis. aammamene asked that the GP consider referring Mr Longley for a specialist cardiology opinion and for him to be reassessed by the GP regarding any further syncopal episodes. The concern is that no action was taken by any GP at the practice to either refer Mr Longley to Cardiology in light of Dr Chambers’ letter or in light of the reported echocardiogram results. Further, no action was taken by any GP to review Mr Longley as requested. The concern is that there is a risk of future deaths if similar lack of action occurs in the future. ACTION SHOULD BE TAKEN In 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 the 47" May 2018. The assistant 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 namely the family of Mr Longley, 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. Rachel Galloway HM Assistant Coroner 22/03/2018 nN
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