Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0338, written 24 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 | 24 Sep 2019 |
|---|---|
| Reference | 2019-0338 |
| Deceased | Francis Hodge |
| Coroner | Briony Ballard |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Lewisham and Greenwich NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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 University Hospital Lewisham 1 CORONER I am Briony Ballard, Assistant Coroner, for the coroner area of Inner London 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 23 November 2019 this jurisdiction commenced an investigation into the death of Mr Francis Hodge. The investigation concluded at the end of the inquest on 30 August 2019. The conclusion of the inquest was that Mr Hodge died as a result of the unintended consequences of medical treatment. 4 CIRCUMSTANCES OF THE DEATH Mr Hodge died on 16 November 2018 at University Hospital Lewisham due to a perforated colon. Seven days prior Mr Hodge had undergone an elective laparoscopic repair of multiple incisional hernias. These had developed at the site of previous abdominal surgeries. Additionally Mr Hodge suffered with pre-existing diverticular disease. The surgery had proceeded without complication. The subsequent development of the perforation was within an area away from the operation site and was very unexpected. It is likely it represented the coincidence of a bowel rendered vulnerable by pre-existing pathology returning to normal bowel function following surgery. 5 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) At inquest I was told that on discharge Mr Hodge was given inadequate discharge advice. He was advised to rest as much as possible and that if he were to remain in severe pain in a week’s time he should return. (2) The consultant who undertook the surgery explained that such discharge advice was not what should have been provided to a patient following this surgery. The patient should have been told to be concerned about and to look out for: breathlessness, pus or redness, and / or pain which would not settle. (3) Mr Hodge was suffering breathless the night before his collapse and pain which would not settle. He however, did not want to seek medical advice I am told, 1 because he was following what he had been told to do on discharge. (4) I was also told that no patient information leaflet existed for this type of surgery as it was not a common type of procedure. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 November 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person , the deceased’s son. I 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. 9 [DATE] [SIGNED BY CORONER] 2 24 September 2019
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.
University Hospital Lewisham Medical Director’s Office Lewisham High Street London SE13 6LH Tel: 020 8 333 3000 www.lewishamandgreenwich.nhs.uk 31 October 2019 Ms B Ballard, HM Assistant Coroner HM Coroner’s Office – Inner London South Southwark Coroners Court 1 Tennis Street London SE1 1YD Sent via email only to: Dear Ms Ballard Re: Mr Francis Hodge – Regulation 28: Prevention of Future Deaths I write in response to your Regulation 28 report following the inquest into the death of Mr Francis Hodge. Thank you for highlighting your concerns, in respect of this case, which I have now had the opportunity to look into. The response required from Lewisham and Greenwich NHS Trust (hereafter ‘the Trust’) is in relation to the following concerns: (1) Mr Hodge was given inadequate advice on his discharge from hospital after surgery. (2) No patient information leaflet existed for this type of surgery as it was not a common type of procedure. Mr Hodge underwent an elective laparoscopic repair of multiple incisional hernias at University Hospital Lewisham on 9 November 2018. Sadly, he died seven days later, on 16 November 2018, at the same hospital, from a perforated colon. On discharge from hospital, after his elective surgery, he was verbally advised to rest as much as possible and that, if he continued to be in severe pain, in a week’s time, he should return. At the inquest, the consultant who undertook the surgery explained that such discharge advice was not what should have been provided to a patient following this surgery. Mr Hodge should have been told to be concerned about and to look out for: breathlessness, pus or redness, and / or pain which would not settle. Mr Hodge was suffering from breathlessness the night before his collapse and pain which would not settle. He, however, did not want to seek medical advice because he was following what he had been told to do on discharge. Mr Hodge was given verbal advice only, upon his discharge from hospital, following elective surgery. Patients listed for elective surgery at the Trust should be given an information leaflet at their preoperative assessment appointment. About four years ago, the Trust commissioned a service from a company called Eido Healthcare, whereby a library of nearly 400 treatment-specific patient information leaflets can be accessed, printed and handed to patients at their preoperative assessment appointment. These leaflets form part of the informed consent process and provide specific information regarding the procedure as well as relevant phone numbers for the patient to contact in case of concerns. Mr Hodge should have been handed the information leaflet specific for laparoscopic hernia repair. However, on review of his case notes, it cannot be demonstrated that this leaflet was handed to him and I apologise for this omission. The Trust has commenced a communication exercise to remind staff in preoperative assessment to ensure that the appropriate information leaflet is handed to patients and to document that this has been done. An audit of the provision of these leaflets will be completed by December 2019 to ensure that the communication strategy has been effective. These information leaflets are available online and their availability is going to be included in the induction programmes of newly appointed medical staff with an emphasis on providing these leaflets during consultation. I sincerely apologise to Mr Hodge’s family for the distress caused by his untimely death after a planned surgical procedure. Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues raised. If you require anything further then please do not hesitate to contact me. Yours sincerely, Dr Elizabeth Aitken Medical Director
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