Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0127, written 1 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2018 |
|---|---|
| Reference | 2018-0127 |
| Deceased | Christine Withers |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Dudley Group NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive/Medical Director, The Dudley Group NHS Foundation Trust 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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 9 January 2018, I commenced an investigation into the death of Mrs Christine Withers. The investigation concluded at the end of the inquest on 23 April 2018. The conclusion of the inquest was a short form conclusion of Natural Causes. The cause of death was: 1a Carcinomatosis b Small Cell Carcinoma of Bronchus 4 CIRCUMSTANCES OF THE DEATH i) Mrs Withers was a 72 year old lady with a medical history including a diagnosis of small cell carcinoma of the lung. She was receiving second line chemotherapy with palliative intent. She also had leg cellulitis. ii) Blood tests ordered by her GP on the 15 November 2017 confirmed she had low potassium levels and was admitted to Russells Hall Hospital on the 16 November 2017. iii) She was initially treated with intravenous potassium replacement for hypokalaemia (level 2.2). Initially she made some good progress but later in the evening her condition declined rapidly and she became more agitated and distressed. iv) An emergency call was issued around 11.15pm for a suspected fluid overdose. Furosemide was administered to try and correct the overload. Despite further treatment her condition continued to decline rapidly and sadly she passed away on the 17 November 2017 and was treated with anticipatory medication for end of life care. 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 1 [IL1: PROTECT] circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Evidence emerged during the inquest that no repeat blood tests were performed to measure the potassium levels despite this being recommended by the Consultant at the ward round in the morning. 2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. You may wish to consider further reviewing the guidance on managing patients with hypokalaemia and monitoring of potassium levels. 2. You may also wish to consider reviewing the communication and training issues identified during the course of the inquest. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 June 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. 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. 9 1 May 2018 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
Ref: Reg28/CW/Jun18 INHS The Dudley Group NHS Foundation Trust Russells Hall Hospital DUDLEY West Midlands DY1 2HQ 22 June 2018 Private and Confidential Mr Zafar Siddique, Senior Coroner Black Country Coroner’s Court Jack Judge House Halesowen Street Oldbury West Midlands B69 2AJ Dear Mr Siddique, Re: Response to Regulation 28 Report to Prevent Future Deaths — The late Mrs Christine Withers | am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest, and your ruling on 23 April 2018 in respect of the late Christine Withers. | should extend again the condolences of the Trust to Mrs Withers’ family. The MATTERS OF CONCERN are as follows: 1. Evidence emerged during the inquest that no repeat blood tests were performed to measure the potassium levels despite this being recommended by the Consultant at the ward round in the morning. 2. There was inadequate communication by nursing staff with the family who expressed concerns. about the decline in Mrs Withers. The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting. On review of the patient’s medical and nursing notes it was clearly documented that a number of conversations were had with the family regarding treatments and the medical plan in place for Mrs Withers. Staff, at the time, did feel that they had communicated effectively and that they were acting on the clinical assessments and needs of the patient. However, staff had documented that the family at times, appeared unhappy with the answers given. Upon reflection, staff have revisited this episode of care and have concluded that they had not focused sufficiently on the family’s emotional wellbeing and the stress that they were under at this very difficult time and agree, that they should have offered more support to the family. Chairman: Jenni Ord Chief Executive: Diane Wake As this was a large family, it may have been more beneficial to have appointed a lead person within the family to cascade information to the rest of the relatives, or arrange a meeting to discuss the best way of communicating in the future. In response to this sad event all the staff within Ward C4 are working with our palliative care champion to complete the in-house palliative care competencies which comprehensively covers communication with patients, families and carers. | trust the information provides assurances to you that The Dudley Group NHS Foundation Trust has taken appropriate action to address the matters of concern raised. Yours faithfully, Diane Wake Chief Executive Enc (1) Chairman: Jenni Ord Chief Executive: Diane Wake
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