Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0351, written 26 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Oct 2018 |
|---|---|
| Reference | 2018-0351 |
| Deceased | Timothy Mason |
| Coroner | Roger Hatch |
| Coroner area | North West Kent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Maidstone and Tunbridge Wells NHS 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.
ANNEX A 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. The Chief Executive, Maidstone & Tunbridge Wells NHS Trust 2. NHS England 1 | CORONER | am Roger Hatch, senior coroner, for the coroner area of Kent (North-West) 2 | 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. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On 15" August 2018 | commenced an investigation into the death of Timothy Alastair Mason, aged 21 years. The conclusion of the inquest was that the medical cause of Timothy's death was ‘a. Meningococcal Septicaemia. The narrative verdict was due to the failure to diagnose and treat Timothy at Tunbridge Wells Hospital and had he been correctly treated he probably would not have died. In addition, during the course of the investigation it was clear that Timothy had not been vaccinated with Men ACWY as his medical records confirmed. It appeared from the evidence that there were considerable concerns for the provision of the vaccination of people of Timothy's age, in the way they were informed of the availability of the vaccine, the computer records of the way GP’s were informed and notified by NHS England and monitored and what steps are being taken to improve the system to ensure people are notified, advised and monitored to ensure they receive the vaccination in the future. 4 | CIRCUMSTANCES OF THE DEATH On the 16 March 2018 Timothy had been unwell for several days and had been seen by his GP. His symptoms worsened, and he attended Tunbridge Wells Hospital at 3.30 am. He was given fluid resuscitation and antibiotics. At 07.45 he was seen by ee told he had a virus and was sent home. Timothy became worse and returned to the hospital on the same day at 15.15 where he was given treatment despite which he died at 21.46. In addition, it was clear from the evidence from the Saxonbury House Medical Group that Timothy had not received the Men ACWY vaccination it was unclear whether he had been invited to have the vaccination, or had been and decided not to. There seems considerable doubt as to how GP surgeries arranged for the vaccination and the way NHS England provided the program for the doctors and monitored the Notification of the vaccine to ensure anyone of Tim’s age would receive the vaccination.. 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 could 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 reasons for the failure to correctly diagnose and treat Timothy on the 16 March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done. (2) Why was Timothy discharged home on the morning of the 16 March 2018 when he was clearly very unwell and tests had not been carried out. (3) What steps have been taken by the Trust to avoid this situation happening again to another patient in the future. (4) What training is being given to the doctors and nurses to avoid this situation in the future. (5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine. ( ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of 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" December 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 REI Misiones & Tunbridge Wells Trust and NHS England. | have also sent it to Saxonbury House Surgery who may find it useful or of interest. | 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 Seronet—4 —— seed [DATE] g ; ; a WI [SIGNED BY CORONER] C_ AN a
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.
Mr Roger Hatch HM Senior Coroner for North West Kent Maidstone Coroner’s Court Archbishop’s Palace Maidstone ME15 6YE Professor Stephen Powis National Medical Director 6th Floor, Skipton House 80 London Road SE1 6LH 7th March 2019 Dear Mr Hatch, Re: Name: Date of Death: 16 March 2018 Regulation 28 Report to Prevent Future Deaths Timothy Alastair MASON Thank you for your Regulation 28 Report dated 26 October 2018 concerning the death of Mr Timothy Alastair Mason on 16 March 2018. Firstly, I would like to express my deep condolences to Mr Mason’s family. The Regulation 28 Report concludes Timothy Mason’s death was due to the failure to diagnose and treat Mr Mason at Tunbridge Wells Hospital following his attendance at the Trust’s emergency department on 16 March 2018. A contributing factor was that Mr Mason had not been vaccinated with the Men ACWY vaccine. Following the inquest, you raised concerns in your Regulation 28 Report (Report) to NHS England and Maidstone and Tunbridge Wells NHS Trust regarding Mr Mason’s management at the Trust on the day of his death and the fact that he had not been vaccinated against Meningitis C. I am in receipt of a copy of the response to your Report from Mr Miles Scott, Chief Executive of Maidstone and Tunbridge Wells NHS Trust (Trust) and have seen the action plan produced by the Trust. I have asked the South East Regional Medical Director to follow this up directly with the Trust to ensure that the actions from this tragic incident are completed. With reference to your final point, Saxonbury House Medical Group (Practice), and all GP practices that signed up to General Medical Services (GMS) enhanced services in 2015/16, were required to offer the vaccination by actively calling eligible young people age 18 years on 31 August 2015, and opportunistically offering the vaccine to those age 19 years on 31 August 2015, and up to the age of 25 years by 31 March 2016. Health and high quality care for all, now and for future generations As part of the GMS contract the practice had a responsibility to ensure that administrative processes were in place for the service they signed up to, including adequate vaccination call and recall systems. letter that It would appear from , a GP partner at the practice, reported at the inquest, that, whilst Timothy did form a part of the cohort of patients who should have been invited to receive the meningitis vaccination, the practice was unable to evidence whether he had ever been invited for the vaccination. His medical records demonstrated that he had not received the vaccination. Furthermore, the practice did not opportunistically offer Timothy the vaccination during appointments with his GP in the following years, because the Medical Information System (EMIS) the practice relied on to prompt such reminders only offered reminders about selected vaccines and did not include Men ACWY unless specifically activated to do so. As a result of this incident, the practice has acted to ensure that the vaccination has been offered to all eligible patients. I can also confirm that the practice has now switched on the necessary alerts prompting the offer for patients who have not received the Men ACWY vaccination. The practice has also written to EMIS requesting that Men ACWY is added to the list of vaccines flagged up in the alert box as a routine. All local practices have been written to and asked to check that the Men ACWY vaccination alert is activated and patients invited from the relevant cohort. During 2018/19 GP practices have continued to opportunistically offer the vaccine to anyone up to the age of 25. This includes those who may have missed the opportunity to be immunised as part of the schools-based programme. In 2019/20 NHS England, will continue to offer the opportunistic service and has committed to undertake a national review of the vaccination and immunisations arrangements (https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract- 2019.pdf) which will include a review and clarification of the expectations around call/recall arrangements, reducing the risk of this incident recurring. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Professor Stephen Powis National Medical Director NHS England Health and high quality care for all, now and for future generations
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