Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0199, written 18 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jun 2019 |
|---|---|
| Reference | 2019-0199 |
| Deceased | Shahida Begum |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Community health care · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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East London Coroners MISS N PERSAUD SENIOR CORONER Walthamstow Coroner's Court, Queens Road Walthamstow E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REF: 9030 16th June 2019 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Alwen Williams CEO Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, Ei 1BB And HER Medical Director, Newham Co-operative, Royal Docks Medical Practice, 21 East Ham, Manor Way, London, E6 5NA 1 CORONER lam Miss N Persaud Senior Coroner for East London 2 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 3 INVESTIGATION and INQUEST On 26/11/2018 | commenced an investigation into the death of Shahida Begum. The investigation concluded at the end of the inquest 13th June 2019. The conclusion of the inquest was a narrative conclusion: Mrs Begum presented with signs and symptoms that should have triggered further clinical observation and investigation on the 9 July 2018. She was diagnosed with muscle sprain and no further investigation was undertaken at that time. She then presented to hospital on the 10 July 2018 with signs of obvious sepsis. Despite treatment at this time, she passed away from the effects of an invasive Group A streptococcal infection. Had she received further observation and investigation on the 9 July 2018, it is likely that her death would have been avoided. 4 CIRCUMSTANCES OF THE DEATH Mrs Begum became unwell on the evening of the 3 July 2018, She was unable to obtain an appointment with her registered GP and visited an out of hours GP on 6 July 2018. This GP diagnosed a urinary tract and throat infection and commenced treatment with trimethoprim and ibuprofen. Mrs Begum continued to deteriorate and on the 9 July 2018 she attended A&E. She was streamed by a doctor who directed her to the GP co-operative. The clinical streaming took place before her vital observations were taken. The streaming doctor later became aware of the observations, but did not change his decision to direct her to the GP. Her observations in A&E at that time should have triggered referral to A&E, where further observation and investigation should have been carried out. Instead, she was assessed by a GP who diagnosed muscular sprain and prescribed pain-killing medication. This GP should have recognised the need for further monitoring and review and should have directed her to A&E. On the 10 July 2018 she collapsed in her GP surgery and was taken as an emergency to hospital. She was found to be in obvious sepsis and despite treatment at this time, she passed away from an invasive group A streptococcal infection. She passed away in Newham University Hospital on the 10 July 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 untess action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is: The current system in place at Newham University Hospital is that a clinical streamer will make a decision about the destination of the patient (GP clinic; urgent treatment centre or A&E), before clinical observations are taken by the triage nurse. The decision is based upon an “eyeballing” check of the patient and a brief history from the patient. It was considered by myself, (as Coroner), by an independent emergency medicine expert and a senior doctor from Newham University Hospital that a safer system would be for the streamer to have the clinical observations available to them before they see the patient. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe both organisations - Barts Health NHS Trust and the Newham Co-Operative, (working together) - 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 123" August 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 Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons -E BE 1 .s)27¢); I | have also sent it to Mr Matthew Cole (Director of Public Health) and the CQC, who may find it useful or of interest. | 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. 18/06/2019 Signature Oph -— Miss N Persaud Senior Coroner East London
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.
NHS Barts Health NHS Trust Trust Headquarters Executive Offices Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80, Newark Street London E Report compiled for Her Majesty's Coroners, Walthamstow e mail: oT Dear Ms Nadia Persuad 13" August 2019 RE: Mrs Shahida Begum — Report to Prevent Future Deaths — STEIS 210377 Following receipt of the Regulation 28 Report into the above patient, | am writing on behalf of Barts Health NHS Trust to clarify the actions taken by the trust to prevent future deaths. We reviewed the report in a meeting held 4" July 2019, with representatives from the Emergency Department, GP Cooperative, Urgent Care Centre, Govemance team and CCG. Action to Address: “It was considered by myself (as Coroner), by an independent emergency medicine expert and a senior doctor from Nevham University Hospital that a safer system would be for the streamer to have the clinical observation available to them before they see the patient’ We reviewed the initial assessment team functioning, to identify ways to address the above issue. We also aimed to ensure there were no unintended negative consequences from changes to the pathway, such as an overall increase in assessment time, which could have an adverse impact on other patient groups. Since this incident we have changed our procedures so that the vital sign records are taken and made available to the streamer before the streaming decision is made. We have also provided additional training for streamers and will continue to do this on an ongoing basis to ensure streamers are aware of the importance of abnormal clinical observations when assessing the suitability of patients for assessment in the urgent treatment centre. Yours sincerely Professor Alistair Chesser Barts Health Chief Medical officer Hsgas? qo <6/ 1NHS Newham GP Co-operative Ltd Newham General Hospital Glen Road, London E13 8SL Tel. No: 020-7511 4448 Fax No: 020-7474 7127 Nadia Persaud Senior Coroner Walthamstow Coroners Court Queens Road Walthamstow London E17 8QP Your reference NP/sc/9030 08.09.19 Dear Ms Persaud Re: Mrs Shaida Begum, reply to letter dated 18th June 2019 Thank you for your letter and detailed report. | am writing in my capacity as Medical Director of the Newham GP Co Operative. Newham GP Co Operative provides out of hours medical services for GP Practices throughout Newham. it also provides Extended Hours GP services (booked GP appointments) at 4 HUB practices based in different locations throughout Newham (GP surgeries). The GP Co Op also holds a sub-contract from the Barts Health NHS Trust to provide streaming services within the Urgent Care Centre at Newham University Hospital. Following the sad death of Mrs Shahida Begum on 10" July 2018, | worked with the Emergency compartment consultant o draw up a concise internal incident investigation report. | enclose a copy of this as it makes a number of recommendations. Those relating to the GP Co Operative are as follows: | have met the GP’s involved with the care of Mrs Shahida Begun: | have discussed their involvement with her care and the diagnoses of Sepsis and the ability to recognise early signs of Sepsis. | have undertaken an audit of consultations fo and PY have referred themselves to the General Medical Council for a review of their involvement in this case. [ Registered in England and Wales Company No. 02969668 Registered Office - Newham NHS Urgent Care Centre Newham General Hospital, Glen Road, London E13 8SL 1NHS| Newham GP Co-operative Ltd Newham General Hospital Glen Road, London E13 8SL Tel. No: 020-7511 4448 Fax No: 020-7474 7127 All reception and clinical staff at Newham GP Co Operative are required to do annual Sepsis training (since Aug 2018) All patients discharged home with an infective illness from Newham GP Co- operative are given the Sepsis Trust Patient Information Leaflet (copy attached) Each consulting room in Newham GP Co-Operative has a laminated copy of the Sepsis Trust Triage Tool An audit was undertaken for 20 streamed patients to review appropriate Sepsis screening and guidelines were being followed. | enclose a copy of the concise internal incident investigation report and the Sepsis Trust Leaflet with advice for Patients being discharged home, with an infective Illness. g fo! ent Care. A einer of suggestions were made to improve the safety of the screening process as recommended in your letter: __ working within the Newham GP Co-Operative a re alerted to a fact Registered in England and Wales Company No. 02969668 Registered Office - Newham NHS Urgent Care Centre Newham General Hospital, Glen Road, London E13 8SL a NHS: Newham GP Co-operative Ltd Newham General! Hospital Glen Road, London E13 8SL Tel. No: 020-7511 4448 Fax No: 020-7474 7127 _ that any NEWS score above 2 will require further investigation and monitoring. © | attended the serious incident meeting at Newham hospital on 9"" July 2019 wit Emergency Primary Care Consultant) to discuss the changes recommended at the meeting with on 4m July 2019, Newham GP Co Operative is committed to working closely with our colleagues in the Emergency and Urgent Care Centres at Newham University Hospital. We have good working relationships with the staff and clinicians in both units. The Newham GP Co Operative greatly appreciates the advice and guidance, (and Education) provided by the consultants in the Emergency department at Newham University Hospital | hope the actions that have been taken both individually by the Newham GP Co- Operative and working with Barts NHS Health Trust reflect how seriously we have taken the death of Mrs Shahida Begum. We are committed to learn from the event and the recommendations in your letter dated 18" June 2019 and the attached report. On behalf of The Newham GP Co Operative | would be very happy to receive any further instructions or advice Yours Sincerely ws Medical Director Newham GP Co Operative Registered in England and Wales Company No. 02969668 Registered Office - Newham NHS Urgent Care Centre Newham General Hospital, Glen Road, London £13 8SL
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