Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0118, written 1 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 | 1 Apr 2019 |
|---|---|
| Reference | 2019-0118 |
| Deceased | Marcie Tadman |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal United Hospitals Bath 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.
M. E. Voisin Her Majesty’s Senior Coroner - Area of Avon 13th March 2019 REF: 8772 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Royal United Hospital, Bath 2. Accountable Office, BANES CCG CORONER lam M E Voisin Senior Coroner for Area of Avon 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/S/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 04/07/2018 | commenced an investigation into the death of Marcie Joan TADMAN. The investigation concluded at the end of the inquest 12th March 2019. The conclusion of the inquest was Natural Causes Contributed to by Neglect CIRCUMSTANCES OF THE DEATH Marcie Tadman died on 5th December 2017 at Royal United Hospital, Combe Park, Bath. She had been admitted to hospital on 4th December 2017 with pneumonia and parapneumonic effusion. She was not referred to the regional unit for treatment of this condition. She had sepsis and there was a failure to recognise and to manage and/or treat sepsis. There were failures to follow the procedures and protocols set nationally or by the hospital. The communication each and every time when discussing Marcie between members of the team was unsatisfactory. All handovers failed to take the opportunity to review Marcie with fresh eyes. The combination of: poor communication between all staff caring for Marcie; the failure to follow any hospital protocols; the lack of proactive review and poor decision making came together to contribute to her death. The medical cause of death: 1a Disseminated group A streptococcal infection including empyema, bronchopneumonia and pyelonephritis Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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. — RUH | heard from the independent expert Dr. Ninis that the only opportunity for Marcie to be picked up with fresh eyes would have been at another ward round. | understand that this would be an opportunity for a Consultant to take a step back and review the notes, charts, PEWS and results; examine the patient and to make a plan. In Marcie’s case everyone agreed that all of the information was there in her records but no one carried out this exercise; there was and is no second ward round on the paediatric ward at the RUH. | indicated to the RUH that | had received further information from | | in relation toa second ward round and this is attached. Accountable Offices for BANES CCG | was also made aware at the inquest that there is no High Dependency Unit (HDU) facility on the RUH paediatric ward for children in their care and this was something that they were hoping to provide but needed to create a business case to the Accountable Offices for BANES CCG for this. In Marcie’s case she should/would have been placed in such a unit had one been at the RUH at the time. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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 23" 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. COPIES and PUBLICATION | have sent a copy of my report to the chief coroner and to the following interested persons — family, | land to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. | 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. 01/04/2019 le Signature Lo ME Voisin Sénior Coroner Area of Avon we Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
28th May 2019 HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton BS48 1UL Dear Madam Marcie Joan Tadman - Response to Regulation 28 Report Directors Office Royal United Hospital Combe Park Bath BA1 3NG Tel: 01225 824032 www.ruh.nhs.uk … Please see the Royal United Hospitals Bath NHS Foundation Trust’s response to the Regulation 28 Report issued on 1st April 2019. 1) There is no second consultant ward round on the Paediatric Ward The Trust has identified that an additional consultant evening session (4 hours) would be required each day to enable it to deliver a second ward round which would not only encompass new admissions but any patient about whom a concern had been raised, including patients receiving critical care. This is not a change in practice that the Trust has been able to deliver immediately. The ability to do this is directly linked to the provision of a Paediatric Critical Care Unit and therefore the plans outlined below presented to the commissioners take clear account of a second ward round being integral to this development. As the Learned Coroner also raised concern about the lack of a permanent paediatric High Dependency Unit (referred to here as Paediatric Critical Care), the Trust has, on 21st May 2019, shared a briefing paper with its commissioners, detailing what would be required to deliver paediatric critical care. This sets out a requirement to do the following: 1. Increase in medical staffing to provide an additional evening ward round. 2. Increase in nursing staffing to ensure rota can provide a 0.5:1 ratio for a Paediatric Critical Care Unit. 3. Invest in additional equipment, eg monitoring. 4. Redesign the ward to establish a fit for purpose Paediatric Critical Care Unit on the children’s ward. If the Trust’s Commissioners are satisfied with the Trust’s proposals, the RUH are aiming to deliver not only twice daily consultant ward rounds, but paediatric high dependency care by Winter 2019. The position of the Commissioners will be set out in their response to the Regulation 28 Report forwarded to them, however, if they were not in a position to support the Trust’s paediatric critical care plans, the Trust would still be looking for additional funding to support twice daily consultant ward rounds. The RUH would like to offer its assurances that it continues to review the other actions and improvements identified during this tragic inquest and it is satisfied that the improvements already made to matters such as handover documentation have increased the safety of the children on the paediatric ward. The Trust is willing to provide a further update in relation to the progress that has been made concerning twice daily consultant ward rounds and the creation of a critical care unit in six months’ time, if that would provide additional reassurance to the Court and Marcie’s family. … We trust that this response offers you sufficient assurances in relation to our actions following the Inquest into this tragic case. Yours sincerely James Scott Chief Executive cc. Tracey Cox, Chief Executive Officer, BSW STP …
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