Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0010, written 10 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2019 |
|---|---|
| Reference | 2019-0010 |
| Deceased | Richard Lockley |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Paula Clark Chief Executive University of North Midlands Hospital Trust Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6€QG CORONER | am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South 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 September 2018 | commenced an investigation into the death of Richard John Lockley aged 72 years. The investigation concluded at the end of the inquest on 8 January 2019. The conclusion of the inquest was ‘Trauma from accidental falls exacerbated by delay in suitable feeding’ with the cause of death being ‘Aspiration pneumonia due to C1/C2 cervical spine fractures’. CIRCUMSTANCES OF THE DEATH Mr Lockley had throat and neck cancer. In June 2018 he fell at his home and broke his neck but still could mobilise. On 26th July while attending County Hospital as an outpatient he fell and had to be admitted. He needed to wear a neck collar. He was a complex case and suitable feeding had not been sorted out by the time he died in the hospital on 11th September. 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) Mr Lockley’s condition was a complex one but following discussions it was decided that he should be admitted to a gastroenterology ward at the Royal Stoke University Hospital for a radiologically inserted gastrostomy. Mr Lockley was at County Hospital. There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. | wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke. (2) | am always cautious about making reports involving resources but there also appears to have been difficulties in actually finding a gastroenterology bed at Royal Stoke for Mr Lockley. | raise this just in case anything can be realistically be done about this. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7" March 2019. 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 copy of my report to the Chief Coroner and to HE widow of the deceased. | have also sent it to your legal department 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 Coroner. AOE... W4AL Hs, 2019 Andrew A Haigh HM Senior Coroner for Staffordshire (South) No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 sscor@staffordshire.gov.uk
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 of North Midlands NHS Trust Trust Ref: INQ/158/19 Royal Stoke University Hospital Executive Suite Springfield 18 March 2019 Newcastle Road Stoke-on-Trent Staffordshire H M Senior Coroner ST4 6QG No 1 Staffordshire Place Stafford Tel: 01782 676612 ST16 2LP Dear Mr Haigh Richard John LOCKLEY Further to previous correspondence, | am pleased to provide a response to your report under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of Richard John Lockley. Recorded Circumstances of the Death Mr Lockley had throat and neck cancer. In June 2018 he fell at his home and broke his neck but still could mobilise. On 26 July 2018, while attending County Hospital as an outpatient he fell and had to be admitted. He needed to wear a neck collar. He was a complex case and suitable feeding had not been sorted out by the time he died in hospital on 11 September 2018. Cause of death was given as 1a: aspiration pneumonia; 1b: C1/C2 cervical spine fractures. Concerns During the course of the inquest H M Coroner, felt that evidence revealed matters giving rise for concern. In the Coroner's opinion there is a risk that future deaths will occur unless action is taken and the matters of concern are as follows: 1. Mr Lockley’s condition was a complex one but following discussions it was decided that he should be admitted to a gastroenterology ward at the Royal Stoke University Hospital for a radiologically inserted gastrostomy (RIG). Mr Lockley was at County Hospital. There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. | wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke. 2.1. am always cautious about making reports involving resources but there also appears to have been difficulties in actually finding a gastroenterology bed at Royal Stoke for Mr Lockley. | raise this just in case anything can be realistically done about this. Page 1 of 1 .Y Commented 39 prove wopreeun Magy Action Taken Following the inquest, the Trust has reviewed matters raised by H M Coroner and the following response outlines the Trusts position: 1. In relation to optimising communication between our two hospital sites, it is agreed that Mr Lockley’s pathway fell short of the standard of care that we hope to provide albeit, all the correct multidisciplinary services were involved in his care (ie radiology, gastroenterology, dietetics). Following discussion with the gastroenterology team and the imaging (radiology) team, there are some lessons that we have learned from this case and they include: a. There was a small window of opportunity to place Mr Lockley's RIG (in between episodes of aspiration pneumonia) and where this cannot be achieved, NG feeding should be commenced as first line treatment; RIG and PEG are never considered appropriate for urgentlemergency procedures. This should have been communicated more clearly to the treating team. b. When reviewing this case retrospectively, it is not imperative that a patient has a bed on the gastroenterology ward for RIG placement and feeding — many of the acute medical wards at the Royal Stoke site should be able to facilitate this method of feeding and this should be considered in the future if there is a shortage of beds on a particular ward. We will ensure that this is communicated to other areas via our communications page. Mr Lockley could have been transferred in a more timely manner had an alternative ward been considered. 2. Managing available beds across both sites is a task which requires constant adjustment and supervision and the Trust has various measures to ensure that patients receive the appropriate treatment with minimal delay. This includes the measures below: a. If there is a patient at County who requires procedures that are only performed at Royal Stoke, the Site Matrons and Matrons for Patient-Flow collaboratively arrange a treatment appointment at Royal Stoke, book the patient transport, arrange treatment as for any other day patient and then arrange for transfer back to the ward at County following the procedure. This process has been followed on many occasions for different specialities. b. If the patient requires an overnight bed at Royal Stoke due to the nature of the procedure being undertaken, then additional measures can be taken. All intra-Trust repatriations are assessed on a daily basis and added to the Repatriation Board at the Site Office (both local patients and regional patients coming from external Trusts). Facilitation of a transfer is discussed three times per day at the Bed Meeting with the Site Matron and the Patient- Flow Co-ordinators; updates on transfers are discussed verbally between the Site Matrons on both hospital sites (ie County and Royal Stoke). Bed availability can change frequently and prioritisation of patient need is required — for example, a poly-trauma patient being transferred from a tertiary centre to the trauma centre may mean that various bed moves need to be considered if the bed capacity is full. c. The Site Matron at County will communicate with the ward and escalate, within the Division, any significant delays in treatment. In addition to the above, the Trust is currently looking to ‘RAG rate’ all requests to transfer a patient based on clinical need and the wait for transfer, to support decision making and appropriate use of resources. | sincerely hope that this report provides the Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mr Richard ° gh lt, Page 2 of 1 sts ml V/s Comentnes vo ergeiren 2 mairg bows of stat “sys John Lockley seriously. The Trust strives to provide a high standard of care to all patients and | am grateful to you for raising these concerns on this occasion. Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours sincerely Helen Ashley ACTING CHIEF EXECUTIVE rv? ° Ses ele 3YYS = S < Communes 9 gion .) Surgueaun — Mays Page 3 of 1
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