Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0107, written 29 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 | 29 Mar 2019 |
|---|---|
| Reference | 2019-0107 |
| Deceased | Ann Corfield |
| Coroner | Anthony Mazzag |
| Coroner area | Manchester City |
| Category | Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Acute Hospitals NHS Trust · Greater Manchester Mental Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Sir David Dalton, Chief Executive
The Pennine Acute Hospitals NHS Trust
Trust Headquarters
North Manchester General Hospital
Delaunays Road
Crumpsall, Manchester
M8 5RB
Neil Thwaite, Chief Executive
Greater Manchester Mental Health NHS Foundation Trust
Trust Headquarters
Bury New Road
Prestwich, Manchester
M25 3BL
1 CORONER
I am Anthony Mazzag H.M. Assistant Coroner for the area of Manchester City.
2 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.
3
INVESTIGATION and INQUEST
On 18th July 2016, an investigation was commenced into the death of Ann
Corfield who died at the North Manchester General Hospital on 3rd July 2017.
She was 71 years of age.
The Inquest, sitting with a Jury concluded on 7th February 2019.
The Jury found the following as the medical cause of death:-
1. (a) Massive pulmonary thromboembolism; due to
(b) Deep Vein Thrombosis in the Leg; due to
(c) Dehydration, secondary to depression with catatonia.
The conclusion of the Jury was:-
Narrative: The deceased died as a result of not being given regular doses of
enoxaparin and the failure to assess capacity contributed to by neglect.
1
4 CIRCUMSTANCES OF THE DEATH
Mrs Corfield was 71 years of age when she died. She lived with her partner,
. She had two children from her previous marriage; a daughter
and a son,
. On 29th May 2016, Mrs Corfield
was admitted to the Royal Oldham Hospital (ROH). She had a urinary tract
infection and
was also concerned about a marked change in her
behaviour. She had withdrawn socially over the preceding months and was
depressed in mood. When she attended hospital, it was discovered that she
had very low sodium levels. She was treated for this and made slow but good
progress. By about 13th June, her sodium level had been corrected.
Despite the improvement in her sodium levels, her mental health deteriorated
significantly. She was eating very little, if anything, and oral fluid intake was
very low.
On admission to ROH, Mrs Corfield was assessed at high risk of developing a
thromboembolism and was prescribed an anticoagulant drug, Enoxaparin.
However, she refused Enoxaparin on a large number of occasions during her
time at ROH.
On 28th June 2016, Mrs Corfield was detained in hospital under section 2 of
the Mental Health Act 1984 as a result of her deteriorating mental health. She
was transferred to a mental health unit called Park House run by Manchester
Mental Health Trust for possible treatment of her psychiatric condition. At Park
House, Mrs Corfield was diagnosed with a severe psychotic depression.
Essential treatment in the form of electro-convulsive therapy (ECT) was
planned by
continued to take very little oral fluids and she became dehydrated. Her
condition deteriorated to such an extent that it was no longer safe to administer
ECT. Intravenous fluids could not be administered at Park House due to the
fact there were no suitably qualified nurses. Further, Mrs Corfield did not
receive prophylactic anticoagulation in Park House. Although a prescription for
Clexane was drawn up on 30th June, it was never administered.
, Consultant Psychiatrist. Unfortunately, Mrs Corfield
Due to her physical deterioration, Mrs Corfield was transferred to North
Manchester General Hospital (NMGH) on 30th June, where, after spending
several hours waiting in the Accident and Emergency Department to be seen
by a doctor, she underwent intravenous fluid resuscitation. She then stabilised
very quickly from a physiological point of view. However, late on 6th July, she
suffered a cardiac arrest and died in the early hours of 7th July.
5 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.
2
The MATTERS OF CONCERN are as follows:
Re: Pennine Acute NHS Trust
1. I heard evidence at the Inquest staff at Park House were not aware that
Mrs Corfield was receiving an anticoagulant in the form of enoxaparin
whilst she was a patient at Royal Oldham Hospital to reduce the risk of her
developing a VTE or that she had refused this medication whilst a patient
ROH. I received written evidence from
that the Pennine Acute
Trust has in place an Adult Transfer Policy and a Form should be
generated which includes details with regards the patient’s medication and
most recent observations. However, the evidence I heard from
Consultant Psychiatrist at Park House, was that his unit still does not
receive a written handover.
,
2. Dehydration clearly played a part in Mrs Corfield’s death. I heard evidence
at Inquest that Fluid Balance Charts were poorly completed indeed some
of them were not completed at all or contained errors with simple
arithmetic. At the Inquest, I heard conflicting evidence about the
usefulness of fluid balance charts. Witnesses who were employed by
Pennine Acute Trust tended to place more reliance on the results of blood
tests. However,
charts in a patient like Mrs Corfield who had a history of chronic kidney
disease because blood tests were an ‘insensitive measure’ of hydration. I
received helpful written evidence from
Director of Nursing for Medicine at Royal Oldham Hospital, dated 31st
January 2019, which, at paragraph 17, shows there are still ongoing
problems with the way fluid balance charts are completed some two and a
half years after Mrs Corfield’s death.
emphasised to me the importance of FBC
who is the Divisional
Re: Manchester Mental Health Trust
1. I heard evidence that although Mrs Corfield was at high risk of developing
a VTE, following her admission to Park House on 28th June, prophylactic
anticoagulation was not prescribed for her until 30th June when a
prescription for clexane (enoxaparin) was issued. Further, although
clexane was prescribed, it was never administered to Mrs Corfield.
2. Further, I also heard evidence that the staff at Park House were not
trained to administer intravenous fluids. This meant that Mrs Corfield had
to be transferred to a North Manchester Hospital for intravenous fluids
when she was in urgent need of specialist psychiatric care and treatment.
was left extremely frustrated that he was
I formed the view that
unable to treat Mrs Corfield with intravenous fluids whilst she was a
patient at Park House.
3
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and your organisation have the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by Tuesday 28th May 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.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:-
Secretary of State for Department of Health and Social Care
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.
9 Signed:
Date:
Mr Anthony Mazzag
Assistant Coroner
Manchester City Area
29th March 2019
4
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