Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0204, written 28 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 | 28 Jun 2018 |
|---|---|
| Reference | 2018-0204 |
| Deceased | John Worthington |
| Coroner | Margaret Jones |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| Category | Community health care and emergency services 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.
IAN S SMITH CORONER’S CHAMBERS, LL.B, Hon DUniv > 547 HARTSHILL ROAD, HER MAJESTY’S CORONER STOKE-ON-TRENT ST46HF Tel: (01782) 234777 for the Fax: (01782) 232074 Stoke-on-Trent and North Staffordshire Email: coroners@stoke.gov.uk Coroner’s Area REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HE Audiem Medical Practice Healthcare Governance Manager Patient Safety, Royal Stoke University Hospital 1 CORONER | am Margaret J Jones HM Assistant Coroner for Stoke-on-Trent & North Staffordshire 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/S/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 18" july /2017 t commenced an investigation into the death of John Robert Maltby Worthington. The investigation concluded at the end of the inquest on 28th June 2018. The conclusion of the inquest was:- The deceased was a 67 year old male. During the late evening of 3rd April 2017 he was carrying a suitcase up the stairs at his home address when he lost his balance, falling backwards. He was able to call for an ambulance. Paramedics arrived at 8.36pm. The deceased was taken to the Royal Stoke University Hospital, Stoke-on-Trent where he was treated for a head injury. He said he had fallen from 4 steps in height. Pain in his back and neck were noted but other observations were within normal parameters. An x-ray and scan were not considered to be necessary. He declined to stay in hospital overnight and was discharged home the same evening. On Sth April 2017 the deceased complained to his daughter of a sore chest saying he had fallen from the top of the stairs. He was relatively immobile and experienced worsening chest and back pains over the following 2 weeks. On the 12th April 2018 he called an ambulance again complaining of chest pains but declined to go to hospital. He contacted his GP to review the paramedics ECG. The doctor asked him to call to see her and made an appointment for him the next day. A further ECG was not considered necessary. Examination revealed tenderness in the lower back region. A full set of observations were not recorded and no further investigations were considered necessary. On 16th April 2017 the deceased called for an ambulance and was taken the Royal Stoke University Hospital with ongoing back pains. He was subsequently found to have L1 fracture and transverse process fractures L2-L4, healing left 11th and 12th rib fractures and bi-basal consolation. He was treated for pneumonia and a spinal abscess was drained. He deteriorated and died in the Royal Stoke University Hospital on 29th June 2017. A post mortem examination gave the cause of death as bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The conclusion at the inquest was that the deceased died from an accidental fall. He had been examined by clinicians but his injuries remained undiagnosed for a two week period. | is my statutory duty to report to you. CIRCUMSTANCES OF THE DEATH Reason: fall with multiple fractures. _ _ - 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 wilt occur unless action is taken. In the circumstances it The MATTERS OF CONCERN are as follows. — (1) The deceased attended A&E on the 4" April 2017.He had a very significant head injury 10 cm long requiring 15 stiches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting condition appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered. (2) Mr Worthington persistently complained of back pain. He saw his GP on the 13" April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or not recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem . ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that Dr Verso and the Royal Stoke University Hospital 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 24" August 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 Chief Coroner and to the following interested persons:- 1 NE ca cctter of the deceased) 2. Stoke-on-Trent Clinical Commissioning Group Smithfield One Building, Stoke-on-Trent ST1 4FA | 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. 28/06/2018 Signature Zanes Margaret J Jofres HM Assistant Coroner Stoke-on-Trent & North Staffordshire
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.
LEGAL SERVICES DEPARTMENT
Please quote Our Ref on all correspondence
OUR REF:
YOUR REF:
RA/396736-001
16 August 2018
Ms Margaret Jones
Assistant Coroner for Stoke-on-Trent and North Staffordshire
By email only: coroners@stoke.gov.uk
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1 PEMBERTON ROW
LONDON
EC4A 3BG
Telephone: 0333 043 4444
Membership: 0333 043 0000
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Email: info@mddus.com
Website: www.mddus.com
DX 446 London Chancery Lane
Dear Ms Jones
Inquest touching upon the death of Dr John Robert Maltby Worthington
Response to Regulation 28 Report on behalf of
I write in relation to the above matter, with which I am assisting Dr Verso.
I note that on conclusion of the inquest on 28th June 2018, you made a Regulation 28 Report to
and the Royal Stoke University Hospital. This is a response to that report on behalf of
I understand that
Person.
the disclosure relating to this inquest.
attended the inquest as a witness of fact and not as an Interested
not therefore legally represented at the inquest and I have not seen any of
I note from the Regulation 28 Report that your concern relating to
take and/or record a full set of observations.
relates to a failure to
consultation with Dr Worthington, I would
While I do not wish to rehearse the detail of
like to point out that
has obviously reflected on this case a great deal and is of the view
that there were many aspects of the care provided that were of an appropriate standard; which I
have highlighted below.
Dr Worthington had contacted the Audlem Medical Practice [“the Practice”] on 13th April 2017 for
wanted to assess Dr
a review of an ECG carried out by the paramedics the previous day.
Worthington and review the ECG in person and asked him to attend the Practice for an urgent
appointment that morning.
saw Dr Worthington, she took a full history and documented that the pain in Dr
When
Worthington’s chest and back had worsened the previous evening though it had improved by the
time he was seen in the Practice.
THE MEDICAL AND DENTAL DEFENCE UNION OF SCOTLAND
Chief Executive Officer & Secretary, Chris Kenny
A COMPANY LIMITED BY GUARANTEE INCORPORATED IN SCOTLAND No. 5093
REGISTERED OFFICE: MACKINTOSH HOUSE 120 BLYTHSWOOD STREET GLASGOW G2 4EA
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examined Dr Worthington and found that he was not short of breath, his pulse was 92
and his heart sounds were normal.
listened to Dr Worthington’s chest and noted that it
was clear with good entry throughout. There was no bruising or swelling visible on Dr
Worthington’s back or chest and there was no midline bony lumbar spine tenderness.
noted that Dr Worthington was tender just lateral to L1 and L2 on both sides, and over his lower
ribs posteriorly and anteriorly.
reviewed the ECG changes and suggested to Dr Worthington that the ECG was repeated
in hospital at a routine outpatient appointment.
recorded that Dr Worthington did not
think this was necessary and preferred to take analgesia as required and self-monitor for any
change or worsening of symptoms.
felt that she provided a high standard of care to Dr Worthington at this consultation;
having insisted that he attended the Practice for a face to face consultation and the carrying out a
detailed assessment.
clinical opinion at the time was that there were no untoward signs
of head injury and there were no clinical signs at the time to suggest that any further
investigations were needed.
had listened to Dr Worthington’s chest and concluded that
the lungs were clear.
With regards to the criticism of failing to take and/or record a full set of observations,
agrees that she has not recorded Dr Worthington’s blood pressure or O2 saturations.
cannot recall now whether she undertook these observations.
documenting a full set of observations in future.
will be more aware of
examined Dr Worthington she did not feel that an x-ray of the ribs/lumbar spine
When
was indicated given that Dr Worthington was not suffering from any midline lumbar spine bony
tenderness. In retrospect however,
accepts that an x-ray may well have picked up the
fractures sustained by Dr Worthington which in turn may have led to a different outcome. Having
is now more likely to send patients of a similar age
reflected on this aspect of the case,
for x-rays in future after any significant trauma.
In conclusion therefore the learning points that
follows:
has taken from this incident are as
Always take and document a full set of observations when examining patients in future;
and
Consider referrals for x-rays in older patients when they have suffered a significant trauma.
is completing an online course in record keeping and has also taken this opportunity to
review the GMC’s guidance on record keeping.
In addition,
Coroner when requested and this point has also been discussed at a Practice-wide level.
also now appreciates the importance of providing a detailed report to the
Upon receipt of the Regulation 28 Report, I can confirm that
self-referred to the GMC.
The GMC have considered the matter and sought medical advice and have closed their enquiry. I
enclose a copy of
self-referral and the GMC’s response.
I hope that the actions described above provide you with the assurance that this matter has been
taken seriously by
.
Please do not hesitate to contact me if
can be of any further assistance.
Yours sincerely
SOLICITOR
Direct Dial:
Email:
020 3668 7059
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