Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0353, written 24 Oct 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 Oct 2019 |
|---|---|
| Reference | 2019-0353 |
| Deceased | Julie Morrey |
| Coroner | Andrew Barkley |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
ANNEX A 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: 1. Ms Tracy Bullock Chief Executive, University Hospital of North Midlands Trust Headquarters City General Site Newcastle Road Stoke-on-Trent ST4 6QG CORONER | am Andrew Barkley, senior coroner for the coroner area of Stoke-on-Trent & North Staffordshire 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 24" January 2019 | commenced an investigation into the death of Julie MORREY aged 58. The investigation concluded at the end of the inquest on 22" October 2019. The conclusion of the inquest was that Julie MORREY died as a result of ‘Natural causes contributed to by neglect’ and the medical cause of her death was:- 1a Acute renal failure complicating chronic renal failure post renal transplant for focal segmental glomerulosclerosis/acute tubular necrosis and glomerulonephritis with smail thrombosed right kidney. 1b Bronchopneumonia. 1c Chronic obstructive pulmonary disease and multifactorial immunosuppression. ll Ischaemic heart disease, lack of fluids. CIRCUMSTANCES OF THE DEATH The deceased passed away in the Royal Stoke University Hospital, Stoke-on-Trent on 10th January 2019 having admitted herself there on 7th January 2019. She had a number of pre-existing medical conditions, the most significant of which was a transplanted kidney which she had had since 2016. Believing that she was suffering with a chest infection, she visited her GP on 4th January 2019 but seif-presented to Accident and Emergency on 7th January 2019 where she was recognised as suffering from renal failure and bronchopneumonia. Despite timely review by a renal specialist, she was not provided with adequate fluids for over 24 hours by which time her condition had worsened and despite admission to the ICU she deteriorated and died. 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. There was a clear lack of communication between the hospital departments as to which department was responsible for the patient after she was assessed by a renal | specialist and a plan made for her care and whilst she awaited a bed on the Renal Unit during which time she was looked after on the AMU. During this time she was without fluids for over 24 hours. 2. There was a clear failure by nursing staff to pro-actively manage her condition due to a lack of policy, procedure and professional responsibility to the patient. 3. There was no review of the patient by a senior clinician for 24 hours following her admission and whilst she awaited a bed on the Renal Unit. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 Friday 20" December 2019. | the coroner may extend the period only following a written application. 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. DE Medical Director, UHNM 2. Deputy Legal Services Manager, UHNM 3. daughter of the deceased | 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. ZL GZ 24™ October 2019 ee aa p reene he
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} University Hospitals of North Midlands NHS Trust Trust Ref: INQ/101/19 Royal Stoke University Hospital Executive Suite Springfield 18 December 2019 Newcastle Road Stoke-on-Trent Staffordshire Mr A Barkley ST4 6QG H M Coroner Coroner’s Chambers Tel: 01782 676612 547 Hartshill Road Stoke on Trent ST4 6HF Dear Mr Barkley Julie MORREY' Further to previous correspondence, | am pleased to provide a response to your report under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of Julie Morrey. Recorded Circumstances of the Death The deceased passed away in the Royal Stoke University Hospital on 10 January 2019 having admitted herself there on 7 January 2019. She had a number of pre-existing medical conditions, the most significant of which was a transplanted kidney which she has had since 2016. Believing that she was suffering with a chest infection, she visited her GP on 4 January 2019 but self-presented to ED on 7 January 2019 where she was recognised as suffering from renal failure and bronchopneumonia. Despite timely review. by a renal specialist, she was not provided with adequate fluids for over 24 hours by which time her condition had worsened and despite admission to the ICU she deteriorated and died. Concerns During the course of the inquest H M Coroner felt that evidence revealed matters giving rise for concern. In his opinion, there is a risk that future deaths will occur unless action is taken. The matters of concern are as follows: 1. There was a clear lack of communication between the hospital departments as to which department was responsible for the patient after she was assessed by a renal specialist and a plan made for her care and whilst she awaited a bed on the Renal Unit during which time she was looked after on AMU. During this time she was without fluids for over 24 hours. 2. There was a clear failure by nursing staff to pro-actively manage her condition due to a lack of policy, procedure and professional responsibility to the patient. 3. There was no review of the patient by a senior clinician for about 24 hours following her admission and whilst she awaited a bed on the Renal Unit. Action Taken Following the inquest, the Trust has reviewed matters raised by H M Coroner and the following response outlines the Trusts’ position in respect of each of the concerns above. 1. The “Renal pathway for patients referred for admission from ED/AMU” has been agreed, which includes detailed advice about clarifying the reason for referral. Trust Internal Professional Standards have been amended with the support of the Medical Director to enhance fitness for purpose and to prevent recurrence of patient care failing due to misunderstanding between departments. 2. Emergency Department (ED) actions a. e. f. The Coroners verdict has been discussed with the senior Nursing Team (1 7 December 2019) and will be shared within the Department setting in the monthly, quality newsletter (December edition). Any patient who requires speciality care is now escalated and discussed within ED huddles and the discussion is documented in the Huddle Log. The senior Matron is now assured that patients requiring speciality input are identified in clinical areas. A daily review is undertaken by Matron/Deputy Matron or Senior Sister. There is increased staffing of senior nurses in ED and 2 senior nurses are now allocated on a planned duty rota. There has been a workforce realignment to ensure all patients are assigned a registered nurse. Reflective statements will be obtained from those involved in the deceased's care. AMU actions a. b. A review of AMU admission documentation has been undertaken. The AMU admission document will identify that medical management has been enacted. There is to be an escalation of care to the Nurse in Charge and/or senior decision maker in circumstances where no management plan has been enacted. This is to be recorded in the nursing documentation and through completion of Datix. 3. Clinical teams would like to reassure H M Coroner that both Renal and Acute medicine do have robust mechanisms for ensuring senior review of patients. in this case, if either specialty had thought the patient to be under their care, they would have had a review. On this occasion, the lack of a consultant review was not a separate or additional error; it all stems from the misunderstanding of allocation at the beginning of the patient’s care. The corrective actions outlined in 1 and 2 above will prevent such a situation from arising in the future. | sincerely hope that this report provides H M Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Julie Morrey seriously. The Trust strives to provide a high standard of care to all patients and | am grateful to you for raising these concerns on this occasion. Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours sincerely Auta Tracy Bullock ‘CHIEF CHIEF EXECUTIVE
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