Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0054, written 7 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2020 |
|---|---|
| Reference | 2020-0054 |
| Deceased | Adrian Ashford |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Lewisham and Greenwich NHS Trust |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1, HE ccical Director Queen Elizabeth Hospital (QEH) Queen Elizabeth Hospital, Stadium Road, London SE18 4QH CORONER lam Andrew Harris, Senior Coroner, London Inner South jurisdiction CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INQUEST I opened an inquest into the death of Mr Adrian Ashford, who died on 15" December 2018 in Queen Elizabeth Hospital, Woolwich (03452-18 JB). An inquest was opened on 7" June 2019 and was concluded on 7" January 2020. The medical cause of death was: la Upper gastro-intestinal bleeding 1b Chronic Peptic Ulcer. The conclusion was Natural Causes. CIRCUMSTANCES OF THE DEATH Mr Ashford suffered from psychotic depression with associated anorexia, weight loss and constipation, about which he was fixated. This was sufficiently severe to have a colonoscopy which was normal and to require admission to a mental health ward. On 11" December he was transferred to A&E with concern about the risk of a GI bleed. He was transferred back as he was stable, without referral to a gastroenterologist. He was admitted to a medical ward the following day, but the risk of bleeding on initial assessment that day was not communicated to the consultant reviewing him on 12". He was rehydrated and his further drop in haemoglobin ascribed to dilution. His circulation was restored with fluids the following day when the haemoglobin and blood pressure further dropped. He died after a massive GI bleed at 15.52 on 15%, from which he could not be resuscitated. Even if the diagnosis of his asymptomatic chronic peptic ulcer had been made by endoscopy before death, it cannot be concluded it would have enabled his life to be saved. MATTERS OF CONCERN The family have made a submission listing eleven concerns, which they say trigger my Regulation 28 duty. These have been carefully considered. Three general remarks are needed; Firstly, individual matters of clinical misjudgment, still less retrospective missed opportunities do not in themselves trigger my statutory duty. Secondly that Mr Ashford’s death and the hearing of this inquest has raised awareness of risks and led to professionals reviewing their clinical practice. Thirdly service developments have addressed some risks such as the urgent cancer referral ptocess and the unified connect care system, linking health care across organizations, which is being implemented. The court has received submissions from QEH, that a PFD report is not required.. CORONER’S MATTERS OF CONCERN are as follows. - 1. Po GP and fF Divisional Medical Director, both gave evidence of the value of having some system for regular weighing, and that it might save lives. This would enable reported weight loss to be verified and quantified and highlight triggers for investigation in a timely manner. But there appears to be no systematic process of recording weights. 2. The consultant in acute medicine, who was on call when Mr Ashford was admitted to A&E on 12 December 2018 by psychiatrists, concerned about the risk of GI bleeding, diagnosed constipation and returned him to a psychiatric bed. It appears he failed to identify the risks of GI bleed identified in ASE on 11", nor the reasons for concern for urgent transfer (dehydration and drop in haemoglobin from 126 to 102g/l). On 14" he also failed to consider referral to a gastro-enterologist, after his blood pressure fell to 83/59 with a tachycardia of 112. He told the court “he was not thinking GI bleed”. Asked about learning from this death, he said that there was no change in his practice, other than increased awareness. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I believe that the NHS Trust medical director would wish to learn of the evidence given in the inquest about the circumstances of this death and are in a position to mitigate or prevent future deaths and consider: a) Whether there is benefit is a systematic process of recording patients’ weights b) Whether the consultant involved in this case would benefit from reporting this case to whoever conducts his appraisals, to consider if he would benefit from further support or professional development. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2"* April 2020. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact COPIES and PUBLICATION Lhave sent a copy of my report to the following Interested Persons: Oxleas Mental Health Trust Valentine Health Tam 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. [DATE] [SIGNED BY CORONER]. 7 February 2020 Andrew Harris, Senidr/ Cor
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 Lewisham High Street London SE13 6LH Tel: 020 8333 3000x 6080 HMSC Andrew Harris Southwark Coroners Court 1 Tennis Street London SE1 1YD April 5, 2020 Dear Mr Harris REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Mr Adrian Ashford I am writing in response to your report dated 7th February 2020 and referenced above. The report raised two matters of concern The matter raised are: , GP and 1. Dr , Divisional Medical Director, both gave evidence of the value of having some system for regular weighing and that it might save lives.. This would enable reported weight loss to be verified and quantified and highlight triggers for investigation in a timely manner. But there appears to be no systematic process of recording weights. 2. The consultant in acute medicine who was on call when Mr Ashford was admitted to A&E on 12th December 2018 by psychiatrists, concerned about the risk of GI bleeding, diagnosed constipation and returned him to a psychiatric bed. It appears he failed to identify the risks of GI bleed identified in A&E on 11th, nor the reasons for concern for urgent transfer (dehydration and drop in haemoglobin from 126 to 102g/l). On 14th he also failed to consider referral to a gastro- enterologist, after his blood pressure fell to 83/59 with a tachycardia of 112. He told the court “he was not thinking GI bleed”. Asked about learning from this death, he said that there was no change in his practice, other than increased awareness. In response to the first matter: Whether there is benefit in a systematic process of recording patients’ weights- In accordance with your recommendation, the Trust agrees that there is a benefit in a systematic process of recording patients’ weight”. To this effect: - The Trust has now implemented a trust-wide electronic patient record system (since May-June 2019). The system enables weight to be consistently recorded electronically which can then be observed by all staff within the Trust - The Trust also has a systematic process in place that covers weekly weights. On admission, there is a nursing task called safety assessment. The safety assessment is a set of assessments bundled into one task. One of the assessments within the safety assessment is the Nutritional Assessment, which includes patient weight/ height/ BMI. This task is then presented automatically on a weekly basis following admission. Weights and heights are then viewable in iView for all staff within the Trust - Additionally, the electronic medicines management system has recently implemented a new way in which to get weights onto the system. There is now an order on the system that can be ordered to any desired frequency. This needs to be completed from the drug chart. Once completed in the drug chart the weights are viewable in iView as well. In response to the second matter: Whether the consultant involved in this case would benefit from reporting this case to whoever conducts his appraisal to consider if he would benefit from further support or professional development- I have met with the consultant involved and we have discussed this case fully. The consultant has conducted a complete case review and reflection that he will use in his annual appraisal. He has changed his own clinical practice and has also made his colleagues aware through a grand round to share the learning. A new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated. I wish to assure you that my team and I take these concerns very seriously and remain open to any suggestions about how we could further improve current processes. Should you have any questions in regard to any of the information in this letter or require any further information please do not hesitate to contact me. Yours sincerely Dr Elizabeth Aitken Medical Director Lewisham and Greenwich NHS Trust
See every Prevention of Future Deaths report matching Lewisham and Greenwich NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.