Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0441, written 18 Dec 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 Dec 2019 |
|---|---|
| Reference | 2019-0441 |
| Deceased | Suzanne Roberts |
| Coroner | James Healy-Pratt |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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
NOTE This form is to be used after an inquest
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Simon Stevens, The Chief Executive of the
NHS
1 | CORONER
!am Mr James Healy-Pratt, assistant coroner, for the coroner area of WEST SUSSEX
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
3 | INVESTIGATION and INQUEST
A seven day Article 2 Jury Inquest was completed on 12" December 2019 into the death
of Suzanne Roberts
4 | CIRCUMSTANCES OF THE DEATH
Miss Roberts was detained as patient under the Mental Health Act, at The Dene, a
private hospital in West Sussex She died on 18" October 2015 at the Dene, from
sudden cardiac arrest arising out of Acute Kidney Injury, Pyelonephritis, Chronic
Dehyrdation and an underlying condition of a High Output Stoma
Miss Roberts had significant physical healthcare issues arising from her High Output
Stoma, which together with other self-harming behaviours, resulted in her admission to
the Royal Sussex County Hospital ("RSCH”) in Brighton, East Sussex, on several
occasions during her seven week stay at The Dene Her last admission to the RSCH
was on 12" October 2015, where she was found to have high potassium and Acute
Kidney Injury Due to systems and communications failings between different
Departments at the RSCH and within the Department of Trauma and Orthopaedics, Miss
Roberts was discharged on 14” October 2015, without knowledge of her initial
admission, renal assessment and recommended in-patient treatment, but with blood test
results that showed high levels of potassium, which led to heart failure and death on 18"
October 2015 The Jury found that there had been neglect
The Jury made factual findings
a) That there was fragmented information sharing between Departments at the
RSCH, resulting in a serious failure to be aware of this patient’s needs
b) There was not an effective system in place at the RSCH for the use of this
patient’s clinical records
c) There was not an effective system in place at the Truama and Orthopaedic
Department at the RSCH for ths use of this patient's clinical records
d) There was not effective communication between all Departments at the RSCH
and within the Department of Trauma and Orthopaedics at the RSCH relating to
treatment of Suzanne Roberts
And that these probably contributed and caused her death on 18" October
2015
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern In
my opinion there ts 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
A Senior Consultant at the RSCH gave evidence at the Inquest in December 2019 and
described the current system of managing patient records at the RSCH as “sub-optimal”
and “flawed” and that a similar death to that of Suzanne Roberts could occur (in the
same circumstance as seen in October 2015) in December 2019
The Jury found the management of patient records at the RSCH to be ineffective, as
was cross Department communication tn relation to patient treatment The Jury also
found ineffective communication and ineffective use of patient records within the
Department of Trauma and Orthopaedics in relation to patient treatment
Whilst there was evidence that £30m had been recently spent by the Brighton and
Sussex Universities Hopsital NHS Trust on a failed attempt to create a single electronic
patient record, the Inquest revealed that
There were at least three software systems in use by different Departments at RSCH,
alongside paper records, and that a portal system, Panda, was also partially in place In
the absence of mandatory rules for the use of those systems or portal, and mandatory
quality assurance about data uploaded to those systems or portal, there Is a continuing
risk of future deaths due to ineffective management of patient records and ineffective
communication across departments at RSCH
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
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 42" February 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 sent a copy of my report to the Chief Coroner and to the following Interested
Father of Suzanne Roberts
Legal Representative for The Dene
Legal Representative for Ms Prowse
+} Legai Representative for Brighton and Sussex University Hospital
| sid Brighton and Sussex University Hospital
lam 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
pP
Date 18 December 2019
Gir Burcbe ef
James Healy-Pratt, Assistant Coroner
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