Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0072, written 26 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2019 |
|---|---|
| Reference | 2019-0072 |
| Deceased | Nathan Mooney |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care 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
THIS REPORT IS BEING SENT TO:
1) Rt. Hon. Matt Hancock MP, Secretary of State for Health and Social Care, 39 Victoria Street,
London, SW1H OEU;
2) Professor lan Cumming OBE, Chief Executive, Health Education England, 1° Floor, Blenheim
House, Duncombe Street, Leeds, LS1 4PL.
CORONER
lam Chris Morris, Area Coroner for Manchester South.
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5S, 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.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 1* june 2017, an inquest was opened into the death of Mr Nathan Mooney who died on 23 May
2017 at Tameside General Hospital, Ashton-under-Lyne, aged 25 years. The investigation concluded
at the end of the inquest which | heard between 14" — 17" January 2019.
At the end of the inquest, | recorded a narrative conclusion that Mr Mooney died as a consequence
of a known complication of previous abdominal surgery which was not identified by treating
clinicians during his lifetime.
CIRCUMSTANCES OF THE DEATH
Mr Mooney was essentially a fit and well gentleman. In 2015, he was diagnosed with a splenic cyst
and elected to have his spleen removed. On 14"* September 2015, Mr Mooney underwent a
Splenectomy, in the course of which an iatrogenic defect was made to his diaphragm. This is a
known complication of the surgery and one which was recognised at the time. The defect was
repaired in the course of the operation.
Following recovery from the surgery, Mr Mooney did not experience any ongoing health problems.
On 20" May 2017, Mr Mooney developed severe abdominal pain of sudden onset, which is likely to
have resulted from the diaphragmatic defect recurring, and his bowel becoming trapped in it. Mr
Mooney attended Tameside General Hospital where he saw a locum Middle Grade doctor who
referred him to the surgical team.
The surgical team on duty in the hospital overnight on that occasion consisted of a locum Middle
Grade surgeon, and a Senior House Officer who had completed a Foundation Year 2 surgical rotation
at the hospital, but was also working a locum shift.
The Senior House Officer reviewed Mr Mooney in conjunction with X-Rays which had been taken.
The Senior House Officer formed the view that the X-Rays showed no abnormality, and discharged
Mr Mooney with advice to return if symptoms did not improve or worsened. This decision was
taken without recourse to a more senior doctor.
A number of Mr Mooney’s symptoms persisted over the following days and on 22"? May 2017, he
attended his General Practitioner who after assessment and consultation with a senior colleague,
decided to adopt a watch and wait approach, again giving advice to seek assistance if symptoms
worsened.
On 23° May 2017, Mr Mooney spoke to the General Practitioner by telephone following a clear
deterioration in his condition. He collapsed at home whilst awaiting an emergency ambulance which
conveyed him to hospital where he died despite attempts to resuscitate him.
A post mortem examination determined Mr Mooney died as a consequence of:
1) a) Colonic herniation and perforation;
b) latrogenic diaphragmatic defect;
c) Elective splenectomy (splenic cyst — operated on 14" September 2015).
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. -
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.
It is apparent that at the time of Mr Mooney’s care, Tameside General Hospital was heavily reliant
on locum doctors to cover shifts.
The court heard evidence of measures which have been taken locally to recruit and retain doctors to
substantive posts, however significant reliance on locum doctors remains an issue. The court heard
evidence from one of the Trust’s Clinical Directors that this resulted from a lack of suitably skilled
doctors in the UK labour market which in turn was compounded by a high attrition rate across a
number of specialities whereby doctors do not complete their post graduate speciality training
within the NHS (choosing instead, for example, to work overseas).
{n addition to the obvious financial consequences of significant locum use for the NHS, the court
heard that it can impact adversely upon continuity of care, and militate against development of
established and effective relationships between clinical teams.
The Clinical Director expressed the view that the current position would be alleviated to a certain
extent by implementation of a system whereby graduates of UK medical schools were (no doubt in
consideration for financial or other support during training) tied-in to a specified period of NHS work
following graduation. Whilst the Clinical Director was aware of previous discussions within the NHS
about such a system, she was not aware of any plans to implement such a system.
It is noted the previous Senior Coroner for this Area, John Pollard, had an exchange of
correspondence with the former Under Secretary for Care Quality, Ben Gummer MP, in 2016 in
which similar issues were raised.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
23°? April 2019. |, 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 iii! Mr Mooney’s father,
| have sent a copy of my report to Tameside Integrated Care NHS Foundation Trust, Tameside
Clinical Commissioning Group, and the Care Quality Commission, 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.
Dated: 26" February 2019
Signature:
Chris Morris HM Area Coroner, Manchester So!
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.
Health Education England Directorate of Education and Quality Floor 2, Stewart House Russell Square Chris Morris London WC1B HM Coroner Manchester South oncon SDN Coroner's Court 1 Mount Tabor Street ye Stockport SK1 3AG 7" May 2019 Dear Sir, Re: Nathan Mooney — Regulation 28 Report response | write in response to your letter of 26 February 2019 addressed tol relating to your report made under the Coroners (Investigations) Regulations 2013 (“the Regulations’). As a recipient of the report, Health Education England (HEE) acknowledges its duty under regulation 29 of the Regulations to give a response to your report, with details of any action that has been taken or which it is proposed will be taken, or an explanation as to why no action is proposed. Upon reading your report, it is noted that you raise concerns about the care Mr Mooney received at Tameside General Hospital prior to his death in May 2017. Specifically, you reference evidence given during your inquest regarding Tameside Integrated Care NHS Foundation Trust's medical workforce and measures which could alleviate pressures on workforce shortages. We write to respond to the points raised in your report that are relevant to HEE’s statutory functions and remit. HEE is an Executive Non-Departmental Public Body sponsored by the Department of Health and Social Care (DHSC), responsible for ensuring that the future clinical workforce is available in the right numbers and has the necessary skills, values and behaviours to meet patients’ needs and deliver high quality care. The Care Act 2014 sets out HEE’s remit and range of roles and responsibilities in detail, including its duty to ensure an effective system is in place for education and training in the NHS and public health system. We note the evidence heard at the inquest regarding the challenges to recruit and retain doctors to substantive posts at the Trust. Ensuring we have sufficient supply of doctors across all grades and specialties is key to excellent patient care. As set out in HEE's draft health and care workforce strategy for England in 2017, the medical profession has seen the largest and most Developing people for health and INHS Health Education England consistent growth of any profession. In addition, an extra 1,500 doctors a year will be trained in the NHS by 2020 in the biggest ever expansion of the medical workforce in England. We will use this expansion to target areas with the most need. We acknowledge that retention challenges can have an impact on the overall numbers of the medical workforce. However, as we do not directly employ NHS medical staff, it is a factor which falls outside of HEE’s remit and responsibilities. In January 2019, the NHS Long Term Plan set out the direction to make the NHS workforce fit for the future. Going forward, we will continue to work closely with our partners across the system to plan how the NHS medical workforce can be further developed and meet patients’ needs. We acknowledge your reference to previous discussions on the implementation of a “tie-in” system for medical graduates, and note the views given at the inquest in relation to this. Any such Policy or response to the views given at the inquest relating to this would fall within DHSC’s responsibility and as such HEE cannot comment further, Yours faithfully, IS ees pee = —_ 5 a... and Quality, National Medical Director Developing people for health and wy Stephen Hammond MP Department Minister of State for Health of Health & 3 View Ber Social Care swinrien Your Ref: 7428/CH 020 7210 4850 Our Ref: PFD-1168849 Chris Morris HM Area Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SKI 3AG } re Wonks, LL April 2019 Thank you for your correspondence of 26 February to Matt Hancock about the death of Mr Nathan Mooney. I was sorry to read of the circumstances of Mr Mooney’s death. If you have the opportunity to do so, please pass my condolences to his family. I note from your report that at the time of Mr Mooney’s death in May 2017, Tameside General Hospital was heavily reliant on medical locums. I note also the evidence given at Inquest suggesting measures the NHS could take to alleviate pressures on its workforce, including placing an obligation on newly qualified doctors to work for the NHS for a period after qualification. On the use of medical locums, the NHS has produced practical guidance to NHS trusts on how to manage medical locum use, to consider alternatives to locums and make better use of bank staff. It is acknowledged that overuse of medical Jocums can put care quality at risk, with a stable workforce whose members have regular appraisals, most likely to deliver high quality care and achieve continuity of services. We know that maintaining a stable workforce is challenging, and the Government is committed to ensuring the NHS has the doctors it needs. We have already made a commitment to making available an extra 1,500 medical school places for domestic students, with the first 630 places taken up in September 2018. By 2020, five new medical schools will have opened to help deliver the expansion. In addition, the Government has considered examples from other industries and ways in which it may be possible to secure better value for money from medical education, alongside improving the working lives of doctors in training. With regard to tie-in, as part of expanding undergraduate medical education, the Government ran a consultation in 2017 and asked specific questions about the concept of return of service for doctors. The feedback from this consultation set out some complex issues and Health Education England (HEE) undertook further detailed work, which now needs to be considered as part of the HEE Enhancing Junior Doctors’ Working Lives programme and the workforce implementation plan. The workforce implementation plan, commissioned by the Secretary of State, is led by Baroness Dido Harding, Chair of NHS Improvement, working closely with Sir David Behan, Chair of Health Education England. The plan will consider the additional staff and skills required and include proposals to grow the workforce; build a supportive working culture in the NHS; and to ensure first rate leadership for NHS staff. The workforce implementation plan will set out how we can achieve the strategic framework set out in the NHS Long Term Plan, published in January 2019, to ensure that over the next ten years the NHS will have the staff it needs so that the NHS workforce has the time it needs to care, working in a supportive culture that allows them to provide the expert compassionate care they are committed to providing. I hope this response provides assurance that the Government is alert to the pressures on the NHS workforce and steps are being taken at a national level to address the current challenges. ver Yours Taree jf} STEPHEN HAMMOND
See every Prevention of Future Deaths report matching Tameside and Glossop Integrated Care NHS Foundation 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.