Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0255, written 23 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Aug 2018 |
|---|---|
| Reference | 2018-0255 |
| Deceased | Patricia Cragg |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: a. Medical Director, Plymouth Hospitals NHS Trust CORONER lam Andrew James Cox, Assistant Coroner for Plymouth Torbay and South Devon. 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/5/paragraph/7 http://www.legislation.qov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 6 February 2017, | commenced an investigation into the death of Patricia Cragg, then aged 74, The Investigation concluded at the end of the Inquest on 23 August 2018. The conclusion of the Inquest was that Mrs Cragg died from a known but rare complication of a necessary medical procedure. The medical cause of death was given as:- 1a) Haemorrhage into Retro Peritoneum (Right Iliac Artery Haemocele Device appropriately placed) 1b) Angiogram/Angioplasty 1c) Unstable Angina from Severe Three Vessel Coronary Artery Atherosclerosis Ul CIRCUMSTANCES OF THE DEATH Mrs Cragg had known severe coronary artery disease. She was not felt to be a suitable candidate for surgery. On 26 January 2017 she underwent a high-risk percutaneous intervention guided by intravascular ultrasound carried out by J At the end of the procedure, the patient reported pain and it was suspected that she was bleeding from the arterial point of entry. The decision was quickly made that she required a CT scan to confirm the diagnosis. Unfortunately, as a consequence of an unrelated road traffic collision, there were a number of other patients also awaiting a CT scan. it took five hours for Mrs Cragg’s CT scan to be performed which revealed an extensive haemorrhage. Before she could be taken to theatre she deteriorated and died in the hospital on 27 January 2017. It was accepted at inquest that earlier surgical intervention may have prevented the outcome although in the context of a number of other significant comorbidities. 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. — ‘o deal with the two simultaneous sets of who accepted this had been a recognised (1) There was a lack of available C emergencies. The inquest heard from 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax weakness for a considerable period of time. | was advised that there were two potential courses of action that could be adopted to overcome this difficulty. First, there could be a second on-call consultant radiologist available to assist the first on-call consultant at times of particularly high demand. Secondly, there could be a facility to open up and run a second CT scanner. This would require the presence of the whole range of staff to include radiographers, porters, et cetera. | was told this was the second time in recent years where there had been simultaneous emergencies that inevitably meant there was a delay in reporting a patient's condition. It seems a decision is required as to whether it is appropriate to allocate additional resource to CT imaging and if so how that additional resource should be deployed in times of unexpected high demand. (2) | was told that the radiology department did not have its own internal major incident policy setting out how to respond to situations like that involving Mrs Cragg. ee Snes me that this was a piece of work he was trying to complete but that he would need input and assistance from his consultant colleagues before being able to do so. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 20 October 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 | have sent a _ of my report to the Chief Coroner and to the following Interested Persons || 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. LQ Dated 7 2/ ¥ 2018 [J for Plymouth To South Devon M Signature. : J) 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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.
NHS} University Hospitals Plymouth NHS Trust RECEIVED 11 OCT 2018 Dr Philip M Hughes MBBS MRCP FRCR Medical Director and Cons. Radiologist Department of Clinical Management Level 07 University Hospitals Plymouth NHS Trust HMCOR ONER Derriford Road eee, Crownhill lias Plymouth PL6 8DH www.plymouthhospitals.nhs.uk 5 October 2018 PRIVATE & CONFIDENTIAL Mr lan M Arrow Senior Coroner Her Majesty’s Coroner for the County of Devon Plymouth, Torbay and South Devon 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Dear Mr Arrow Re: Patricia CRAGG Thank you for your letter of 23 August 2018 and accompanying Regulation 28 report in relation to the aforementioned patient. You identified a number of Matters of Concern in your report which | will respond to in order: There was a lack of available CT resource to deal with the two simultaneous sets of emergencies. The inquest heard ronal accepted this had been a recognised weakness for a considerable period of time. s advised that there were two potential courses of action that could be adopted to overcome this difficulty. First, there could be a second on-call consultant radiologist available to assist the first on-call consultant at times of particularly high demand. Secondly, there could be a facility to open up and run the second CT scanner. This would require the presence of the whole range of staff to include radiographers, porters, et cetera. | was told this was the second time in recent years where there had been simultaneous emergencies that inevitably meant there was a delay in reporting the patient's condition. It seems a decision is required as to whether it is fara) Working in partnership with the Peninsula Medical School 3 VWVA Chairman: Richard Crompton Chief Executive: Ann James “saynO BY Aatss Working in partnership with the Peninsula Medical School Fy appropriate to allocate additional resource to CT imaging and how that additional resource in should be deployed in cases of unexpected high demand. 1. We have a new Emergency Department CT scanner. This is an additional CT scanner. During office hours it rapidly deals with Trauma cases and new emergencies. During out of hours it deals with all on call emergencies. This has not increased the number of scanners available at night, but has significantly improved access and throughput. 2. There has been a culture change in terms of radiology registrar to consultant radiologist communication. The registrars have been encouraged (they were never discouraged) to engage help from the on call consultant at times of high work activity that exceeds their capability (for instance multiple trauma cases). This would improve patient flow and care. It would also reduce any delay in getting new patients scanned. 3. There is a ‘WhatsApp’ communication tool available to the on call radiology consultant to draft in additional reporting capacity in the event of multiple traumas that exceed reporting capacity. 4. We are making plans to increase consultant presence at weekends and CT scanning capacity at weekends. 5. With the staffing that we have, | do not believe that we would be able to have a second tier of on call staff available to open a second scanner at a moment's notice (minimum 2 staff). Rather, we need to be more actively engaged in prioritisation of cases. We also need to remind clinical colleagues of the need to update the radiology team when patient status changes. | was told that the radiology department did not have its own internal major incident policy setting out how to respond to situations like that involving Mrs Cragg. informed me that this was a piece of work he was trying to complete but that he would need input and assistance from his consultant colleagues before being able to do so. We agree that this is a piece of work that would formalise some of what is described above and| will receive full support in its formulation and implementation. We aim to have this ready by 31/12/18 and will share it with you when completed. Yours sincerely age Dr Philip M Hughes Medical Director Chairman: Richard Crompton Chief Executive: Ann James “CsynP
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