Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0092, written 19 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2019 |
|---|---|
| Reference | 2019-0092 |
| Deceased | Graham Tailby |
| Coroner | John Hobson |
| Coroner area | Manchester City |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Care NHS Foundation Trust · Pennine Acute Hospitals NHS Trust · Greater Manchester Mental Health NHS Foundation Trust · Salford Royal NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being sent to: Prof Matthew Makin, MD of NMGH, Penine Acute Hospitals NHS Trust Copied to: Greater Manchester Mental Health NHS Trust c/o Hempsons Solicitors Coroner I am John Hobson, Assistant Coroner for the Manchester City Area. Coroner’s legal powers I 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 19th January 2016 an investigation was commenced into the death of Graham Tailby, aged 58. The investigation concluded at the end of a jury inquest on 8th March 2019 and which was heard before me. The cause of death was found to be: Broncopneumonia 1a 1b Combined sertraline and fentanyl toxicity The conclusion of the inquest was as follows: Mr Tailby died as a result of a combined toxicity of prescribed drugs but it was unclear as to how that toxicity occurred or developed. Circumstances of death Mr Graham Tailby was a patient detained under the Mental Health Act 1983 on Juniper Ward, Park House, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester. On the evening of 22nd December 2015 Mr Tailby was discovered unresponsive in his room during a 1:15 minute observation of a type and frequency that had been carried out consistently throughout the day and during which no concerns were raised by staff tasked with completing observations. Upon discovering Mr Tailby to be unresponsive, an alarm was raised followed by a crash call by way of dialling emergency line 2222. The crash team attended Mr Tailby’s room on the ward where CPR had been commenced by staff attending in response to the alarm. Assessment and appropriate medical interventions were carried out by the crash team utilising equipment from the crash trolley which had been brought to the room, but despite all efforts the decision was taken to cease further action and Mr Tailby’s death was confirmed at 20:00 hours. Coroner’s concerns During the course of the inquest the evidence revealed a matter 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 is as follows. The leader of the crash team gave comprehensive and clear evidence as to the appraisal of Mr Tailby’s situation upon his emergency arrival on the ward in response to the crash call and the decisions that were then taken. His evidence was that he whilst struggling to gain intravenous access to administer relevant drugs to Mr Tailby he had considered the possible use and assistance of a piece of equipment known as an intraosseous drill. The equipment however wasn’t present on the crash trolley which had been brought to Mr Tailby’s room. In the event he was in fact able to secure intravenous access and proceed accordingly. He also acknowledged that whilst the use of an intraosseous drill was an option with which he was familiar, that might not be the case for others and in any event is not a core requirement of expertise of those involved in emergency responses such as that which took place. The point that I raise is that the provision of the intraosseous drill on crash trolleys may provide another route of intervention for those familiar and trained in its use in other circumstances in the future, and having that option may prevent deaths in the context of emergency crash responses to wards for which the Trust has responsibility. Action should be taken In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 Wednesday 15th May 2019. I, John Hobson, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Greater Manchester Mental Health NHS Foundation Trust I 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. John Hobson H.M. Assistant Coroner – Manchester City Area Date: 19th March 2019
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.
Ref: CB Date: 2 April 2019 Sent via email on 02 April 2019 Chris Brookes Chief Medical Officer/Deputy Chief Executive Group Headquarters 3rd Floor Mayo Building Stott Lane Salford M6 8HD Telephone: 0161 206 4657 Dear Mr Hobson Inquest touching the death of Graham Tailby I write in relation to the above inquest that was held before you on 8 March 2019. Following the inquest, you issued a Regulation 28 report dated 19 March 2019, addressed to Professor Matthew Makin, Medical Director of North Manchester General Hospital, Pennine Acute Hospitals NHS Trust (“the Trust”). The Regulation 28 report is copied to Greater Manchester Mental Health NHS Trust c/o Hempsons solicitors. Coroner’s concerns The matter of your concern is as follows: The leader of the crash team gave comprehensive and clear evidence as to the appraisal of Mr Tailby’s situation upon his emergency arrival on the ward in response to the crash call and the decisions that were then taken. His evidence was that he whilst struggling to gain intravenous access to administer relevant drugs to Mr Tailby he had considered the possible use and assistance of a piece of equipment known as an intraosseous drill. The equipment however wasn’t present on the crash trolley which had been brought to Mr Tailby’s room. In the event he was in fact able to secure intravenous access and proceed accordingly. He also acknowledged that whilst the use of an intraosseous drill was an option with which he was familiar, that might not be the case for others and in any event is not a core requirement of expertise of those involved in emergency responses such as that which took place. The provision of the intraosseous drill on crash trolleys may provide another route of intervention for those familiar and trained in its use in other circumstances in the future, and having that option may prevent deaths in the context of emergency crash responses to wards for which the Trust has responsibility. Response Crash trolleys are managed by Pennine Care NHS Foundation Trust and not the Pennine Acute Hospitals NHS Trust. Consequently it is our view that the direction of the Regulation 28 report to the Pennine Acute Trust on this occasion is incorrect. May I respectfully recommend that the Regulation 28 report should be addressed to Pennine Care NHS Foundation Trust who are in a position to effect change following your recommendation. The Trust has discussed this matter with HM Senior Coroner Mr Meadows and he kindly sent over full disclosure. As discussed it would have been beneficial if we had of been notified of the inquest as we would have been better placed to assist and been able to provide a response to explain that the trolleys are not serviced by ourselves. I also note the staff member who gave evidence was not working for the Trust at the time of giving evidence nor where the legal team aware that he had given a statement previously. May I also draw to your attention that Regulation 28(3) of the Regulations states “A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation”. Furthermore, at this inquest, it is understood that you heard evidence from Greater Manchester Mental Health NHS Trust, but did not hear any live evidence from Pennine Acute Hospitals NHS Trust or hear any submissions on behalf of the Trust. It was therefore unfortunate that the Trust was not aware of the Inquest, had not been made an Interested Person or provided with disclosure. Consequently the Trust was not provided the opportunity to submit any evidence to your investigation and was first aware of this inquest following receipt of the Regulation 28 report. Had the Trust been invited to respond to this issue prior to the issuing of the Regulation 28 report, the correct information would have been provided so that the concerns raised would be directed to the appropriate body with the power to effect change and implement learning. I am deeply sorry that Mr Tailby’s family have had a further unnecessary delay in obtaining answers due to the Regulation 28 process. The Trust would have preferred to have addressed the concerns at the inquest for the benefit of Mr Tailby’s family and your investigation and thus avoided the need to issue the Trust with a regulation 28. Yours sincerely Chris Brookes Consultant Emergency Medicine Executive Medical Director, Salford Royal NHS Foundation Trust Chief Medical Officer and Deputy Chief Executive Northern Care Alliance (Incorporating Salford Royal NHS Foundation Trust and Pennine Acute NHS Trust)
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