Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0214, written 12 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2018 |
|---|---|
| Reference | 2018-0214 |
| Deceased | James Sheffield |
| Coroner | Timothy Brennand |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Salford Royal NHS Foundation Trust |
| 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. PY Clinical Director, Salford Royal NHS Foundation Trust, Eccles old road, Salford. M6 8HD. [1 | CORONER I am Timothy William Brennand, Assistant Coroner, for the Coroner Area of Manchester West. 2 | CORONER'S LEGAL POWERS 7 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 26" day of January 2016, I commenced an investigation into the death of James Sheffield, Aged 64 years. The investigation concluded at the end of the inquest on the 31% January 2018. The conclusion of the inquest was: A medical cause of death of: 1a. Global Cerebral Hypoxia 1b. Idiopathic Post-Operative Acute Respiratory Failure II. Disseminated High Grade Renal Carcinoma; Obesity Related Obstructive Sleep Apnoea The Narrative Conclusion was that James Sheffield died as a consequence of the combination of naturally occurring disease and the effects of recognised complications of post-operative recovery following necessary surgical intervention to treat injuries sustained in an accidental fall that had given rise to a susceptibility to respiratory failure on a background of pre-existing complex co-morbidities. 4 | CIRCUMSTANCES OF THE DEATH The deceased had a history of neuro-ischaemic ulcer to the right foot, dyslipidaemia, angina, previous heart failure, previous stroke, hypertension, obesity hypoventilation syndrome and obstructive sleep apnoea. [On the 1* June 2016, the deceased suffered an accidental fall at a shopping _| centre. He was taken to Salford Royal Hospital, Eccles Old Road, Salford and following a full evaluation was discharged with analgesia upon no significant findings being diagnosed. On the 13” July 2016, the deceased was recalled to the hospital upon a clinical review revealing potential abnormality and then diagnosed with a hairline femoral fracture and pelvic metastatic carcinoma which was deemed to be secondary to a carcinoma of the kidney. There was a delay between recall, diagnosis and active surgical intervention in the form of corrective hip replacement surgery that took place without complication on the 11 July 2016. That delay had no bearing upon the outcome. Post-operatively, the deceased received high dependence care within an Intensive Care Unit and made an initial recovery to the extent that that he was stood down to care on ward. Upon transfer to ward, the deceased’s CPAP machine that was intended to accompany him went missing following x-ray procedures undertaken prior to admission on ward. The accepted omission to ensure an important item of medical equipment was transferred and in the possession of the deceased and available for use did not have a bearing on the outcome. At about 1.15pm on the 12" July 2016, suddenly and unexpectedly, for reasons that cannot be established, the deceased suffered a cardio-respiratory arrest. Resuscitation was undertaken promptly. Despite active management of his condition, the deceased failed to regain consciousness. His condition deteriorated until he died on the 17" July 2016. 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. The case involved evidence of the in-patient treatment and care in circumstances where that patient had brought into the hospital their own piece of important medical equipment — in this case a Continuous Positive Airway or “CPAP” machine (also known as an obstructive sleep apnoea machine); 2. Established medical practice, for good reasons, permitted patients to bring into the hospital and utilise their own “CPAP” machine with which the patient would be familiar; 3. However, the evidence that I heard revealed that there was no established system in place to ensure that such a piece of important medical equipment would remain with the patient in the event of transfer of that patient within the hospital from differing wards, units or departments; 4. Whilst I heard evidence that a comprehensive “Report following investigation” had been conducted by Salford Royal Hospital, facilitated by their Governance Manager, in which there was correctly identified the ACTION SHOULD BE TAKEN necessary potential root causes, conclusions and sharing of lessons, proposed monitoring mechanisms, ward to ward transfer documents and electronic record systems that had been put in place — nevertheless, the evidence that I received suggested that there were outstanding protocols and/or policies to be implemented to ensure that following an internal transfer, patient owned medical equipment such as the “CPAP” machine should not only be moved with that patient, but specific measures taken to ensure that it was both immediately available and ready for use to enable the patient to self-care upon completion of the transfer. 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, namely by the 7“ 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: AVMA, Freedman House, Christopher Wren House, 117 High Street, Croydon. CRO 1QG. Hill Dickenson, No.1 St. Paul’s Square, Liverpool. L3 9S) — solicitors for Salford NHS Foundation Trust. Tam 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 __|12" April 2018 Timothy W.Brennand Dated Signed
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.
et Saving lives, NHS) Improving lives Salford Care Organisation OT | Northern Care Alliance NHS Group RECEIVED 23 APR 2018 If calling please ask for: Salford Care Organisation | Salford Royal Hospital, Stott Lane, Salford M6 8HD Our ref: PT/SJB Date: 17" April 2018 Mr T Brennand HM Coroner for Manchester West H M Coroner's Court Paderborn House Civic Centre Howell Croft North Bolton BL 11 QY Dear Sir Re: James Sheffield — Response to Regulation 28 Report | write further to the inquest into the death of Mr Sheffield which concluded on 31 January 2018. | acknowledge receipt of the Regulation 28 report that was subsequently issued on 12 April 2018 and note the concerns outlined. As you are aware, following the conclusion of the Inquest, the Trust wrote to you on 2 February 2018 (a signed copy of the letter was subsequently dated 7 February 2018) in order to outline the prompt action that the Trust had already taken in response to the concerns which you raised at the Inquest. | enclose a further copy of that letter, together with the enclosures, as the Trust’s formal response to the Regulation 28 Report. | trust that the information provided assures you of the prompt action taken by the Trust to ensure that your concerns were swiftly addressed. Please let me know if you require any further information. Yours faithfully Wn ke Medical Director HILL DICKINSON HM Coroner for Manchester West our Ref 1093708 mee ur Ren e wT, Ne fennan nl Doc Ref: 151239355.1 Chea Sa Date: 07 February 2018 Paderborn House Civic Centre Howell Croft North Se Bolton BL 11 QY Dear Sir Re: James Sheffield | write on behalf of my colleague, Joanna Crichton. Further to the assurances given by Fs at the Inquest into the death of James Sheffield which concluded on Wednesday 31 January 2018, the Trust has already now implemented further changes to the ward to ward transfer document on its electronic patient record system in order to address the additional concern raised. A screenshot of the updated document is attached showing the additional information which must be recorded on all transfers. A box requires confirmation that all essential equipment is available, checked and ready to use. The expectation therefore, is that equipment is set up upon transfer. In addition, if “yes is selected, details must be recorded. In the event that “no” is selected an explanation must be recorded to explain why this is the case. | can confirm that these changes are now live and have been fully implemented. In order to accompany these changes, the Trust has circulated a safety alert to all staff to inform them of the changes to the EPR and the reasons far this. A copy of the alert is also attached to this email. In the circumstances, it is clear that the duty to make a Regulation 28 report is no longer engaged since the Trust has already taken steps to put in place measures to prevent the recurrence of the risk identified. Any Regulation 28 report in these circumstances would not have any practical effect and accordingly would not comply with the Chief Coroner 's Guidance Number 5 at Paragraph 5. The Coroner is also respectfully reminded of Paragraph 24 of that same guidance. It is a matter for the Trust to determine what the action should be in order to address the concern. The Trust has put in place additional changes to its ward to ward transfer documentation and process which it determines to be the most appropriate method of addressing the concern. Hitt Dickinson LLP No, 1 St. Paul's Square ere Liverpool L3 eS! hiliickinsof.com Tel: +44 (0)451 600 8000: ‘Tha Hill Dickinson Legal Services Group has offtces In Liverpool, Leeds, Manchester, London, Piraeus, Singapore, Monaco and Fax: +44 (0)15¢ 600 6001 Hong Kong. Hill Dickinson LLP is a limited liability partnership ragistared in England and Wales with registered number OC314079, Is registered office Is at No. 4 St. Paufs Square, Liverpool 1.3 98J. Hill Dickinson LLP Is authorised and regutated by the Solicitors Reguialon Authorily The Trust takes patient safety seriously and wishes to ensure that lessons are learnt where possible. The Trust has taken on board the additional concern identified and has taken prompt action to address that concern. In the circumstances, a Regulation 28 report would be redundant. Please do not hesitate to contact Joanna Crichton or | should you wish to discuss this? Yours sincerely ack cnc PP Partner Hill Dickinson LLP’
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