Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0367, written 12 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Nov 2019 |
|---|---|
| Reference | 2019-0367 |
| Deceased | Pamela Moran |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath & Port Talbot |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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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: CHIEF EXECUTIVE ABMU HEALTH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR 4 CORONER | am Aled Gruffydd, Assistant Coroner, for the coroner area of SWANSEA NEATH & PORT TALBOT 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 29% March 2018 | commenced an investigation into the death of Pamela Moran. The investigation concluded at the end of the inquest on 11!" November 2019. The medical cause of death is 1a) acute on chronic intracranial bleed 2 anticoagulation for metallic mechanical heart valve, osteoporotic fracture of neck of femur and elbow (not operated on) ischaemic heart disease, dementia The conclusion of the inquest as how Mrs Moran came to her death was accidental death. CIRCUMSTANCES OF THE DEATH The deceased was Pamela Moran and she was pronounced dead on the 17" of March 2017 at Morriston Hospital, Swansea. The cause of death was an acute on chronic intracranial bleed caused by a fall in the parking area of Tonna Hospital, where she suffered a fracture to her right hip, right elbow, and a head injury. Pamela was transferred to Morriston Hospital where the fractures to the hip and elbow were diagnosed. A request was made for a CT scan to assess the extent of the head injury however this was refused as a fractured hip and elbow do not fulfil the criteria for a CT head scan to be performed. It was not explained during that conversation however that Pamela was on warfarin, and had suffered a previous chronic subdural haematoma three months prior. This information would have brought Pamela within the criteria of a CT head scan. The CT head scan was eventually performed on the 16" of March 2017, some 40 hours after admission and after Pamela had begun to experience neurological signs. The CT scan showed an acute on chronic intracranial bleed, by which time the only treatment options being palliative care. It was found that there was a total of three missed opportunities (including the above) to ensure that the CT scan was done. It could not be stated whether an earlier CT scan in this case would have prevented death. The circumstances relating to Pamela’s fall at Tonna Hospital has been the subject of a Serious Incident Review by the Health Board and steps have been put in place to avoid a reoccurrence. Accordingly this report is not concerned with the circumstances surrounding the fall but in respect of the matters that arose following it. CORONER’S CONCERNS During the course of the inquest a report from Dr fF instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed. Dr EEEBFonclusion noted at paragraph 6.5.6 that: “Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second do‘ giving advice h e earlier information. The discrepancy between —_— account and Dr account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarifie ie use of structured documentation generated by either or both parties. Dr ee that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned. The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.” 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 were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased’s death, or at the very least improved her prospects of survival. 2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs as: respect of their conversation on the 14" of March 2077. 3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation 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 7 January 2020. |, 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 —_—e to the Chief Coroner and to the following Interested Persons _ | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina 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. — 5, 12 November 2019 CL Ly fegld. seeeeneevens [SIGNED BY CORONER]
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