Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0224, written 11 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jul 2018 |
|---|---|
| Reference | 2018-0224 |
| Deceased | Rita Giles |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| 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.
VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 KAREN HENDERSON, BSC,BM,MRCPI,FRC. . __GILVA D.J-TISSHAW, BA(LAW)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Ms Marianne Griffiths, Chief Executive, Brighton and Sussex University Hospitals NHS Trust 2. EEE Brighton and Sussex University Hospitals NHS Trust 3. Brighton and Sussex University Hospitals NHS Trust 4. Mr K Singh, Clinical Director, Abdominal Surgery and Medicine, BSUH CORONER lam Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 13" March 2018 | commenced an investigation into the death of Rita Elizabeth GILES. The investigation concluded at the end of the inquest on 5 July 2018. The conclusion of the inquest was NARRATIVE CONCLUSION. CIRCUMSTANCES OF THE DEATH See Record of Inquest 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. VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC._. Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 _GILVA D.L.TISSHAW, BA(LAW)HONS oc ne The MATTERS OF CONCERN are as follows: — (1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork. (2) The Trust's own Transfer Policy not adhered too in any respect. (3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later. (4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement. There was a failure to appreciate that as she was already septic when she came in the matter was urgent. From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" September, 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. ER sister of Rita GILES 2. Care Quality Commission VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC. - Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 3. Clinical Commissioning Group 4. Secretary of State for Health, Department of Health 5. Simon Stevens, Chief Executive, NHS England 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. 9 Date: 117 July 2018 . ay BY: Senior Coroner Brighton and Hov
See every Prevention of Future Deaths report matching Brighton and Sussex University Hospitals NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.