Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0129, written 8 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 | 8 Apr 2019 |
|---|---|
| Reference | 2019-0129 |
| Deceased | Tina Tait |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive, Blackpool Teaching Hospitals NHS Foundation Trust [“the
Trust”]
4 | CORONER
| am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
CORONER’S LEGAL POWERS
N
| 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
The medical cause of death was recorded as follows:
1 a Multi — organ failure
1b Complications following surgery to remove an ovarian mucinous
borderline tumour [operated 08/05/18]
2 Polyarteristis Nodosa and Vasculitis
The conclusion was a Narrative conclusion as follows:
Tina Tait died on 16" June 2018 from complications arising from necessary
elective ovarian cystectomy surgery conducted on 8" May 2018. Her death
was more than minimally, trivially or negligibly contributed to by her pre-
existing co-morbidities.
4 | CIRCUMSTANCES OF THE DEATH
On 8” May 2018 Tina Tait underwent an elective and necessary ovarian
cystectomy procedure. At high risk of complications the procedure took longer
|__| to perform than was anticipated primarily due to the extent of adhesions
found. Discharged home on 10" May 2018 Tina was re-admitted to hospital
on 13" May 2018 with bleeding from the surgical wound site. On 17 May
2018 a Consultant General Surgeon performed an emergency surgery and a
perforation of the mid-transverse colon was identified which had most likely
occurred on 8" May 2018 as the surgical wound was being closed. There was
then a period of gradual improvement and consideration was given to
potential discharge from hospital. However during the course of the 14" June
| 2018 a deterioration in her condition was not fully appreciated by hospital |
medical staff and her condition was not escalated to the appropriate level of
clinician. Early the next morning her condition continued to decline and she
became unresponsive and died at approximately 8pm on 16™ June 2018.
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:
The concern | have is that there is a risk of future deaths because the
opportunity to learn valuable lessons following a death is being compromised
by issues pertaining to the quality of record keeping.
Issues have arisen in relation to the quality of accessible clinical records [as in
this inquest concerning Tina Tait] but also in relation to retention and storage of
those records [other investigations — see below] to the extent that the
effectiveness of sudden untoward incident reviews conducted by the Trust has
| been compromised perhaps due to the consequential delay [inevitably leading
to lessons being learnt later than they may otherwise have been] or because
the quality of the review has been affected [missing documentation leading to
internal reviews having to be concluded in the absence of records].
Following Tina Tait’s death the hospital trust undertook a sudden untoward
incident review. This led to a report being compiled and that document was
included in the inquest evidence. One of the authors of that repo (t{ _—_——s
HE clinical Matron] gave extremely helpful evidence at the inquest and
was an impressive witness.
However within the report a learning point was identified namely that the
documentation in the case records had been found to be “at times poor and
illegible”. [Other learning points included the need for improved handover /
continuity of care, learning in relation to the recognition of a deteriorating
patient and correct use of the Early Warning Score chart with appropriate
escalation.] Professionals such as Amanda Langton tasked with investigating
deaths clearly need to be provided with all of the necessary information to be
able to produce an effective review which ensures the right lessons are learnt
| and the risk of future deaths minimised accordingly.
| am concerned that | having found herself trying to review this
| matter in the face of poor and illegible records is a reminder that unless this
| type of issue is not addressed then risks will occur as a consequence. Medical
professionals who take over the care of patients from other staff at handover
need to be able to familiarise themselves with accessible and legible records.
When this does not happen the quality of the care received by patients can be
affected. It seems to me that issues persist as regards the quality of record
keeping within the Trust and that it would be remiss of me not to raise that
concern at this time.
| bear in mind that the quality of record keeping is an issue | have raised with
the hospital trust previously. In October 2017 | sent to the Trust a letter of
concern written in accordance with paragraph 37 of the Chief Coroner’s
Guidance No. 5 (Reports to prevent future deaths). That letter was in relation to
investigations conducted at this court into the deaths of WB and NM. The letter
was felt to be necessary after the inquest into WB’s death had to be conducted
in the absence of documentation which the Trust was unable to locate. In May
2017 this court received from the Trust a Sudden Untoward Incident Review
into the death of NM which had been completed in the absence of some of the
hospital records which could not be located.
| was concerned that an improvement in relation to record keeping was
essential because having access to quality documentation minimises the chance
| of, for example, an untoward clinical incident review being delayed or
remaining incomplete; it avoids the risk that a coroner’s inquest is delayed.
Also, and importantly in my view, it is obviously important that records are
readily available to assist a coronial inquiry or indeed an internal hospita! review
not least in order to ensure any lessons which need to be learnt can be learnt
and for this to be achieved as effectively as possible an accurate record of
events should be available.
In addition to the quality of some of the records relating to Mrs Tait’s care in
hospital, the Trust’s internal review was delayed because the clinical records
could not be located for some time resulting in a delay before witness
statements could be compiled and the Sudden Untoward Incident Review
completed the impact of which was the inquest had to be vacated from the
original court slot allocated to it and re-listed.
Other investigations have been affected by similar issues: a further investigation
into the death of JS ultimately proceeded in the absence of hospital records
which reportedly went missing after the death and could not be found.
In deciding to write this letter | take into account that in response to my letter in
October 2017 [see above] | received a response from the Trust dated qe
December 2017 within which the point was made that “it is worth noting that
the Trust has somewhere in excess of 500,000 sets of patient records and that
| non-availability is a rare event”. The letter went on to helpfully explain that the
Executive Directors had approved a business case for the introduction of an
electronic document management system which would mean paper records
would be immediately accessible to attending clinicians.
Unfortunately, having monitored the situation since then | remain concerned
that the Trust’s procedures in terms of accessibility but also to quality of clinical
records poses a risk of future deaths if those procedures are jeopardising the
| likelihood of the correct lessons arising from a death investigation being learnt.
As stated at the conclusion of the inquest, ultimately | did not find that Mrs.
Tait’s death was caused by or contributed to by the quality of the records or the
delay in them being located. However, this does not prevent me from writing
this letter if there is a concern future deaths may occur and | write this letter
because despite the matter having been raised previously the issue appears to
be ongoing as the investigation into Mrs Tait’s death illustrates.
At the conclusion of the inquest, | indicated to the Properly Interested Persons
| that | proposed to write to Blackpool Teaching Hospitals NHS Foundation Trust a
report in accordance with the provisions of paragraph 7 of Schedule 5 of the
Coroners and Justice Act 2009.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] 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 24" 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 of England & Wales and to
the following Interested Persons:
e Family of Tina Tait
e Care Quality Commission
1am 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.
A.A. Wilsow
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 8" April 2019
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