Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0114, written 3 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Apr 2019 |
|---|---|
| Reference | 2019-0114 |
| Deceased | Terence Thornton |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT iS BEING SENT TO: Dr P Hughes, Medical Director, Legal Department, Level 07, Derriford Hospital, Plymouth, PL6 8DH CORONER lam Andrew James Cox, Assistant Coroner for Plymouth Torbay and South Devon. 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. 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 22 September 2017, | commenced an investigation into the death of Terence Douglas Thornton,then aged 82. The investigation concluded at the end of the Inquest on 3 April 2019. The conclusion of the Inquest was that Mr Thornton died as the result of an accident to which a known complication of necessary medical treatment contributed. The medical cause of death was given as:_ 1(a) Acute Subdural Haematoma 1(b) Fall 1(c) Postural Hypotension I Warfarin Therapy or Deep-Vein Thrombosis CIRCUMSTANCES OF THE DEATH On 16 September 2017, Mr Thornton was admitted into Derriford Hospital following a fall in which he struck his head. He was receiving warfarin for previous DVTs. A CT of his head was reported as being normal. (in fact, a subsequent review identified a subtle, small subdural haemorrhage.) On 17 September 2017, Mr Thornton was discharged to Liskeard Community Hospital arriving at approximately 18:50 hours. At approximately 19:00 hours on 18 September 2017, Mr Thornton was given a dose of enoxaparin. At 07:30 hours on 19 September 2017, he was found comatose in bed. He was taken to Derriford Hospital where a further CT scan revealed a catastrophic expansion of the earlier (missed) subdural haemorrhage. Mr Thornton deteriorated and died in Derriford on 19 September 2017. 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. — BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, | heard evidence from Po at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. EEE told me that this “happens frequently.” 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax (2) | also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 — 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) | would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e- discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. [6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 1 June 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons | | Director of Nursing at Cornwall Partnership Foundation Trust. | 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 3 April 2019 Signature Andrew Cox, Asgistant Coroner, for Plymouth Torbay and South Devon 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mrs A James, Chief Executive, University Hospitals Plymouth NHS Trust CORONER lam Andrew James Cox, Assistant Coroner for Plymouth Torbay and South Devon. 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. http:/Awww.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 22 September 2017, | commenced an investigation into the death of Terence Douglas Thornton, then aged 82. The investigation concluded at the end of the Inquest on 3 April 2019 . The conclusion of the Inquest was that Mr Thornton died as the result of an accident to which a known complication of necessary medical treatment contributed. The medical cause of death was given as:_ 1(a) Acute Subdural Haematoma 1(b) Fall 1(c) Postural Hypotension Il|__Warfarin Therapy for Deep Vein Thrombosis CIRCUMSTANCES OF THE DEATH On 16 September 2017, Mr Thornton was admitted into Derriford Hospital following a fall in which he struck his head. He was receiving warfarin for previous DVTs. A CT of his head was reported as being normal. (In fact, a subsequent review identified a subtle, small subdural haemorrhage.) On 17 September 2017, Mr Thornton was discharged to Liskeard Community Hospital arriving at approximately 18:50 hours. At approximately 19:00 hours on 18 September 2017, Mr Thornton was given a dose of enoxaparin. At 07:30 hours on 19 September 2017, he was found comatose in bed. He was taken to Derriford Hospital where a further CT scan revealed a catastrophic expansion of the earlier (missed) subdural haemorrhage. Mr Thornton deteriorated and died in Derriford on 19 September 2017. 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. The MATTERS OF CONCERN are as follows. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) At the Inquest | heard evidence fron Clinical Director for Radiology at Derriford Hospital. He told me that, currently, there are 44 radiologists working within the Trust. He told me that he believed there was a need for up to a further 16 clinicians across a range of specialities. (2) | also heard evidence ron felt that work pressures may have caused or contributed to the error that occ stance. (3) It is not the first time that shortages of radiology clinicians has been brought to my attention at Inquest. | am aware that there are difficulties in this regard nationally but | am concerned that the 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax problems in Derriford appear to be worsening with the consequent risk that similar fatalities may occur in the future. In the circumstances, it is my duty to report the situation to you so that you may consider what action needs to be taken to address the situation. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 1 June 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 to the following Interested Persons - | 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 3 April 2019 Signature Andrew Cox, Assistant Coroner for Plymouth Torbay and South Devon 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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.
14" June 2019 Your ref; IMA/DR/THORNTON/2369-17 MrA Cox , Assistant Coroner Her Majesty’s Coroner for the County of Devon Plymouth, Torbay & South Devon “1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Dear Mr Cox © Terrance Douglas Thornton - deceased University Hospitals | Plymouth NHS Trust. Medical Director and Cons. Radiologist Department of Clinical Management Level 07 University Hospitals Plymouth NHS Trust Derriford Road' Crownhill “Plymouth Tel: Email: www.plymouthhospitals.nhs.u Thank you for your letter of 3 April 2019, addressed to the Chief Executive. Please accept our sincere apologies for the delay in responding. : In your letter, you raised concerns that work pressures may have contributed to the error that occurred. In relation to the issue raised regarding the Consultant Neuroradiologist we can confirm that he reported and checked a total of 39 scans that afternoon (which was a very busy day). There are 5 Consultant Neuroradiologists and on the day in question Saturday 16° September 2017, we can confirm that the neuroradiology rota was covered as planned by a consultant and_a registrar. Subsequent to the incident, the Consultant Neuroradiologist submitted the case for review at the departmental audit meeting. It was also discussed at the departmental discrepancy meeting on 2 November and it was noted that whilst the findings on the CT head were subtle, the use of multi-planar reformatting (looking at it from different angles) and selected windows (reviewing the image on different settings) would have improved the chances of identifying the subtle subdural haematoma. The lessons from the investigation have been shared with the Radiology team. . You also raised concerns about the shortages of radiology clinicians where you recognised that there are difficulties nationally but you are concerned that the problems. at Derriford ‘ appear to be worsening with the consequent risk that similar fatalities may occur in the future. : You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those ~ vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisations business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists. The level of radiology vacancies at University Hospitals Plymouth NHS Trust UHP is fewer than many other Trusts in England. Nationally 6 in 10 Consultant Radiologist vacancies remain unfilled for 12 months or more. (Source: Royal College of Radiologists UK workforce census 2018) | hope the above-serves to provide assurance around the actions we are taking in respect of the problems that you have raised. Please feel free to get in touch, if further information is required. With best wishes. Yours Sincerely Age Medical Director
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