Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0322, written 30 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Sep 2019 |
|---|---|
| Reference | 2019-0322 |
| Deceased | Mary Jones |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of Manchester University NHS Foundation Trust 1 | CORONER | am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 INVESTIGATION and INQUEST On 5" March 2019 | commenced an investigation into the death of Mary Jones. The investigation concluded on the 23% August 2019 and the conclusion was one of Narrative: Died from the recognised complications of an accidental fall in combination with underlying frailty. The medical cause of death was 1a) Hospital acquired pneumonia on a background of congestive cardiac failure and acute kidney injury ; 2) Left fractured neck of femur (operated on), Frailty CIRCUMSTANCES OF THE DEATH Mary Jones had an accidental unwitnessed fall. She was admitted to the Manchester Royal Infirmary (MRI) where she was operated on. She was transferred to Trafford General Hospital for rehabilitation. She was increasingly confused post- admission, probably due to dehydration and pain. On 3 March 2019 she deteriorated rapidly having acquired an acute pneumonia on a background of congestive heart failure and acute kidney injury which in combination led to her death on 3% March 2019 at Trafford General Hospital. 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. — 1. Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer. As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours. The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are low priority and moved where needed; 2. The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival; 3. The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs Jones; 4. The documentation issue was exacerbated by the Trust IT merger having resulted in the loss of a number of key documents. It was unclear how the Trust were managing the risks around lost medical records where the IT merger was at the root of the issue; 5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral; 6. There was no evidence of clear clinical review of the outcome of the fluid charts. 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 25!" November 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 namely 1 EEE on behalf of the family and; 2) Trafford Clinical Commissioning Group, 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. Alison Mutch OBE HM Senior Coroner 30.09.2019
See every Prevention of Future Deaths report matching Manchester University NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.