Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0465, written 16 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 | 16 Sep 2019 |
|---|---|
| Reference | 2019-0465 |
| Deceased | Blaithin Buckley |
| Coroner | Jacqueline Devonish |
| Coroner area | Northamptonshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health 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: na General Council 1 | CORONER i i | am Jacqueline Devonish, assistant coroner, for the coroner area of Northamptonshire 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 11 September 2019 | commenced an investigation into the death of Blaithin Grianne Buckley, aged 26. The investigation concluded at the end of the inquest on 13 September 2019. The conclusion of the inquest was that her death was a Misadventure and that the medical cause of death was: ta. Hypoxic brain injury 1b. Out of hospital cardiac arrest ic. Hanging | 2. Emotionally Unstable Personality Disorder | The jury found that the death had been contributed to by a breach of procedure at St : Andrews in failing to lock the phone booth; an inadequate level of patient history transferred from Wootton Lawn to St Andrews (in particular the previous history of ligature by phone cord): an insufficient process for calling the ambulance service following the incident. 14 | CIRCUMSTANCES OF THE DEATH Ms Buckley died on 30 April 2018 at Northampton General Hospital following being | found hanging in a phone booth on the Bayley Ward at St. Andrews Healthcare on 26 April 2018 at 23:20, whilst on 5 minute observations. Contrary to the Trust policy, the | phone booth door had been left unlocked. | The Trust medical emergency team was alerted to the incident through ascom at 23:23. CPR and life support commenced to good effect. Upon being found Ms Buckley had | | been conscious. She then fell unconscious with fixed and dilated pupils. The experienced medical emergency team returned a pulse and rapid heart beat whilst awaiting arrival of an ambulance. The first ambulance arrived at 00:02, having been called at 23:44. Ms Buckley was transferred to Northampton General Hospital at 00:42 | | in a comatose condition. Brain stem testing on 30 April 2018 recognised that life was i extinct. mm The critica! care consuitant at Northampton General Hospital gave evidence that he suspected that an earlier arrival at hospital would not have altered the outcome as 5 minutes was sufficient to establish perrnanent brain damage. = | CORONER'S CONCERNS 1 During the course of the inquest the evidence revealed matters giving rise to concern. in | my opinion there is a risk that future deaths could 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) The delay in calling for an ambulance to transfer Ms Buckley to the General Hospital in a clear medical emergency. There was no evidence before inquest to explain the delay between 23:20 and 23:44. | Whilst it had been accepted that senior clinicians, with greater medical knowiedge that the paramedics, formed the medical emergency team, St Andrews as a mental health setting was required to transfer Ms Buckley to A&E in any event. i it was unclear whether the policies/procedures requiring the mobilisation of the medical emergency tearn included guidance on whether an ambulance should be called, and when. ACTION SHOULD BE TAKEN in my opinion action shauid be taken to prevent future deaths and | believe you 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 16 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. COPIES and PUBLICATION _ | have sent a copy of my report to the Chief Coroner and following Interested Person - | have also sent it to ho may find it useful or of interest. | arm aiso 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 _ fesponse, about the release or the publication of your response by the Chief Coroner. | 16 September 2019 Jacgueliot Devenish
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.
St Andrew's HEALTHCARE Executive Directorate T:01604 616409 Jaqueline Devonish Assistant Coroner Constabulary Block Angel Square, Angel Street Northampton NN11ED 8 November 2019 Dear Ms Devonish Ref: Blaithin Grianne Buckley deceased Further to the Regulation 28 notice received by St Andrew's Healthcare dated 15 September 2018, I am providing a response to the matter of concern which was the delay in calling for an ambulance to transfer Ms Buckley to the General Hospital. While the evidence provided to the Court indicated that an earlier arrival at the General Hospital would not have altered the outcome in this instance, St Andrew's recognises that there is a need for greater clarity around the recognition of a medical emergency and how and when an ambulance is called. To that end the Charity has taken the following steps: 1) The Charity uses the National Early Warning System (NEWS) recording system to aid the recognition of the deteriorating patient. A 'red -top alert' - ie a Charity wide alerting notice - has been sent out concerning the use of the National Early Warning System (NEWS) chart. This alert has been further discussed at governance meetings at different levels to increase awareness and to confirm the ongoing and correct use of the chart. -Action completed on 10 September 2019. 2) NEWS training is mandatory for all staff as an e-learning module and the training has been refreshed and continues to be rolled out as part of the Immediate Life Support training for all registered nursing staff. 3) The policy concerning the management of a deteriorating patient is being reviewed and refreshed to provide clarity on the actions to be taken in the event of a patient experiencing deteriorating physical health and requiring medical intervention. This is due for implementation on or before 1 January 2020. 4) One specific and significant change in the procedure that has already been implemented is that when a medical emergency is called, an ambulance is also called rather than leaving it to the discretion of the nursing team as was previously the case. This will enable a faster response to medical emergencies. Action completed on 7 November 2019 5) Responses to medical emergencies including ambulance attendances will be monitored in the relevant governance meeting chaired by the Director of Physical Healthcare (the monthly physical healthcare group) with necessary escalation where problems or challenges are found. 6) These changes have been shared with NHSE specialist commissioning (the lead commissioner for St Andrew's) and will continue to be monitored in the regular bi-monthly NHSE St Andrew's Quality meetings. [ ~\ INVESTORS ~JIN PEOPLE Registered Office St Andrew's Healthcare, B,lling Road, Northampton NNl SDG Telephone 01604 616000 Website www srah.org Registered Charity Number 1104951 Old Charity Number 202659 Company Number 5176998 EALTHCA~E Executive Directorate Please do contact me if you require any further clarification or information about this matter and the actions we are taking to address this issue. Yours sincerely Executive Medical Director St Andrew's Healthcare f' '\ INVESTORS ~_JIN PEOPLE Registered Office St Andrew's Healthcare. 8,11,ng Road, Northampton NN1 SDG Telephone 01604 616000 Website www.stah org Registered Charity Number 1104951 Old Charity Number 202659 Company Number 5176998
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