Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0148, written 2 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 May 2019 |
|---|---|
| Reference | 2019-0148 |
| Deceased | Royston Kemp |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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Dictated: 11 April 2019 Sent: 2" May 2019 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. chai of Fitness to Practice, Nursing and Midwifery Council, Ist Floor, 1 Kemble Street, London WC2B 4AN 1 | CORONER Tam Andrew Harris, Senior Coroner, London Inner South. 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 30" March 2016, I opened an investigation and on 26" March 2019 an inquest into the death of Mr Royston Kemp (00822-2016 MM), 85 years, who died at Queen Elizabeth Hospital on 20" March 2016. The medical cause of death of Mr Kemp's death was recorded as follows: 1a Pneumonia b Aspiration c Advanced. Dementia II Fragility fracture of left hip - operated. Infected venous ulcers. Whilst the main cause of death was natural and he was at high risk from his fragility, the immobility from a traumatic fracture was a key contributor to his death. The circumstances that led to the fracture in the care home cannot be determined, 4 | CIRCUMSTANCES OF THE DEATH Mr Kemp was an uncomplaining 85 year old suffering from dementia and with a history of fractures and falls who suffered an unwitnessed traumatic fracture of his left femur on or soon before 26th February 2016 in his care home. He injured his hand and elbow on 25th, had a bruise on his thigh on 26th, had a need for increased analgesia and a swollen leg on 27th. He was examined by a nurse on 27th but not referred to hospital until 28th when a massive bruising was discovered. He was in a poor state. Despite surgery on 29th and rehabilitation he died peacefully at 21.34 on 20th March from a chest infection and dementia. 5 1 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. - A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was: 1) She found one leg more swollen than the other and of a different temperature but took no action 2) She failed to establish the care assistant’s concern or whether she had met the concern before or after her assessment 3) She failed to measure Vital Signs 4) She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Fitness to Practice - Nursing and Midwifery Council have the power to take such action. I send this report to assist you with your assessment. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 27" 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. If you require any further information or assistance about the case, please contact the case a COPIES and PUBLICATION LT have sent a copy of my report to: | [ae & HE (:2ddaughtes) f RadcliffesLeBrasseur for Four Seasons Health Care | $$ arcral Inn for for Queen Elizabeth Hospital And to the nurse concerned (personal details attached in confidence). Iam 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. [DATE] [SIGNED BYCORONER] a
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