Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0172, written 5 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2018 |
|---|---|
| Reference | 2018-0172 |
| Deceased | Rosemary Scott |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| 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.
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. Ms Miller, Chief Executive, Dorset County Hospital, Williams Avenue, Dorchester, DT1 2JY 1 | CORONER I am Brendan Joseph Allen, Assistant Coroner, for the Coroner Area of Dorset 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 23 January 2018, an investigation was commenced into the death of Rosemary Scott, born on the 30" April 1932. The investigation concluded at the end of the Inquest on the 23 May 2018. The Medical Cause of Death was: 1a Bronchopneumonia 1b Rib fractures ic 2 Cardiac failure, Atrial Fibrillation The conclusion of the Inquest was that Rosemary Scott died as a consequence of an accident. 4 | CIRCUMSTANCES OF THE DEATH Overnight on 8" to 9" December 2017, Rosemary Scott suffered a fall at her son’s address, where she was staying at the time. She injured her back. On 9! December, Mrs Scott became a resident at Nazareth Lodge Residential Home in Sturminster Newton. Whilst there, she complained of back pain. Mrs Scott was admitted to Dorset County Hospital on 14‘ December with breathlessness, confusion and drowsiness. She was found to have a chest flail segment and pneumonia. She required positive end-expiratory pressure (PEEP) and was given a bi-level positive airway pressure machine (“BiPAP”), which she tolerated well. Mrs Scott was discharged to Nazareth Resindetial Care Home on 22"¢ December, but was re-admitted to Dorset County Hospital on 25 December. Mrs Scott was suspected to have sepsis, so the “Sepsis Six Pathway” was completed. Venous blood gases were not measured on admission, or at any stage until shortly before her death. There appeared to be no reminder system in place to alert the treating doctors that this had not been done. Mrs Scott was assessed by a consultant on 28" December. He noted that Mrs Scott “needs PEEP — highflow or CPAP”. The next entry in the records indicated that at 13.30 the Charge Nurse “was unable to source any means to provide PEEP”. All High flows and BiPAPs were in use. There were no continuous positive airway pressure machines (“CPAP”) in respiratory medicine. By 20.45, Mrs Scott was provided with a high flow machine. Mrs Scott deteriorated overnight on 29" to 30° December and died at Dorset County Hospital on 30" December. 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. During the inquest evidence was heard that: i. Venous blood gases were not measured on the second admission (25‘ December to 30‘ December), in accordance with the Sepsis Six Pathway. There appeared to be no reminder system in place to address this omission. I heard evidence that measuring the carbon dioxide levels would have assisted in determining whether the high flow machine was providing the level of respiratory support Mrs Scott required. ii. | There were initially no means to provide PEEP to a patient that was deemed to need it, due to all machines being in use, or there simply being no machine in respiratory medicine. 2. Ihave concerns with regard to the following: i. Due to the lack of a reminder system in relation to measuring venous blood gases it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BIPAP or CPAP. I request that a review is undertaken to assess whether there should be a system installed to ensure the staff caring for patients where venous blood gases should have been measured are “reminded” of the need to do so. ii. The insufficient number of machines to provide PEEP to patients who require it. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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, 1 August 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: () (2) (3) 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. 5% June 2018 Brendan J Allen
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.
Dorset County Hospital INHS NHS Foundation Trust Dorset County Hospital Williams Avenue Our Ref: C131 Your Ref: BJA/00106-2018/LJ Dorchester Dorset Telephone: 01305 251150 Fax: 01305 254155 Minicom: 01305 254444 21 June 2018 Mr B Allen H M Assistant Coroner for Dorset The Coroner's Office for the County of Dorset Town Hall Bournemouth BH2 6DY Dear Mr Allen Thank you for your letter dated 06 June 2018, in relation to the inquest touching the death of Rosemary Scott. Your report details two matters of concern, which | will respond to point by point for ease of reference. e Lack of a reminder system in relation to measuring venous blood gases, as you state it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BIPAP or CPAP. You requested that a review is undertaken to assess whether there should be a system installed to ensure that the staff caring for patient where venous blood gases should have been measured are ‘reminded’ of the need to do so. | have been informed that it would be clearly indicated in the medical records that staff within the emergency department had been unable to access veins to gain venous gases. The decision, as to whether these would be clinically necessary would lie with the clinicians. As a patient's condition changes, the clinical review of tests required can change. This is part of the individual clinician’s judgement and assessment of the patient. Clinical opinion on the right treatment options, including tests, does vary according to the patient's needs. Therefore it is not possible to implement a blanket prompt other than the handover process that is already in place. In this case, effectiveness of treatments can also be monitored and assessed in alternative ways, such as using a pulse oximeter. The pulse oximeter ensures safe, non-invasive monitoring of the cardiorespiratory condition of patients in need of care. The Trust does have clinical systems already in place to assist with the monitoring and recording of observations, reporting of test results and general alerts. e The insufficient number of machines to provide PEEP to patients who require it. The medical records dated 28 December 2017, indicate that on only three PEEP machines were available across the hospital and that there was difficulty in locating one for use by Mrs Scott. | have investigated this matter and | would advise you that the Trust actually has 6 machines. However, at the time of Mrs Scott’s admission, two machines had been taken out of service as they were physically damaged and were being repaired. This left the Trust with four units. This concern was discussed at a Divisional level and a plan was put in place. On 27 December 2017, a further unit was taken out of service for infection control reasons, which left three units across the hospital. The unit was decontaminated and returned to service on 29 December 2017. On 28 December 2017, three loan units were rented for a period of two months and were delivered to site on 29 December 2017. This meant that between 08:00hrs to 15:00hrs three units were available, but by 16:00hrs, six units were available. On reviewing the records and the events, Mrs Scott was without the unit for only a few hours and this was neither detrimental to her care, nor a factor in her death. A suitable alternative was in place and in use, as per the consultant's care plan. ! would also advise you that over this period the Trust had no incidents reported in relation to the unavailability of the units, and patient care had not been compromised. This incident was the first reported, therefore there is no evidence of a systemic issue/failure or a trend with respect to safety related to the unavailability of equipment. The rental units were in place within hours of the request being submitted, and a requisition for two replacement units was placed on 25 January 2018. | hope that this addresses your concerns and provides you with assurance that the Trust is ensuring safe, high quality care and the availability of necessary equipment. Yours sincerely Patricia Miller Chief Executive.
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