Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0062, written 28 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jan 2020 |
|---|---|
| Reference | 2020-0062 |
| Deceased | Susan Sterland |
| Coroner | Philip Barlow |
| Coroner area | Northamptonshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Kettering General Hospital NHS Foundation Trust 1 CORONER I am Philip Barlow, 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 8 January 2019 I commenced an investigation into the death of Susan Sterland, age 76. The investigation concluded at the end of the inquest on 23 January 2020. The conclusion of the inquest was that Susan Sterland died of undiagnosed intestinal obstruction. 4 CIRCUMSTANCES OF THE DEATH Susan Sterland was brought by ambulance to the emergency department of Kettering General Hospital on 29th December 2018. She had intestinal obstruction which was not diagnosed. Ms Sterland was diagnosed with constipation and admitted to the emergency decisions unit (EDU). The intention was to admit her to the medical ward but there were no available beds and so she remained on EDU for two nights. During the time she was in hospital she was seen by two experienced Advanced Care Practitioners (ACP) and by one junior doctor (FY1). She was never seen by senior doctor. During the day on 30 December she showed some signs of deterioration. Her condition then rapidly deteriorated during the late evening of 30 December 2018 but her care was not escalated. She collapsed and died early on 31 December 2018. 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. – This was obviously a very busy time at the hospital. However, Ms Sterland was in the hospital for some 40 hours, she was not getting better, there were signs that she was deteriorating during the late morning and afternoon of 30 December, there was a plan to admit her to a ward but there were no beds available. My concern is that in this situation she was not seen by a senior doctor. If Ms Sterland had been seen by a senior doctor the evidence was that she would have had further investigation which would have led to earlier diagnosis of the obstruction and may have altered the outcome. 1 The evidence at the inquest suggested that there are some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust would wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or 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 26 March 2020. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Ms Sterland’s family as Interested Persons. I 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. 9 28 January 2020 Philip Barlow 2
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.
Affiliated Teaching Hospital
Our Ref: SS Inquest – PFD Response
Mr Phillip Barlow
Assistant Coroner for Northamptonshire
Executive Offices
Rothwell Road
Kettering
Northants
NN16 8UZ
Main Switchboard: 01536 492000
Direct Dial:
Fax: 01536 493767
Web: www.kgh.nhs.uk
When calling, please ask for
24th July 2020
Dear Sirs
Inquest concerning the death of Susan Sterland – PFD Response
Following the inquest of Susan Sterland that took place on the 23rd January 2020, Assistant Coroner
considered his duty to issue a Prevention of Future Deaths Report (PFD) had been satisfied due to
the evidence which he heard as part of the inquest.
The Coroner raised the following concern in relation to the Accident and Emergency Department –
“my concern is that she was not seen by a senior doctor. If she had been seen by a senior
doctor, the evidence was that she would have had further investigations which would have
led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at
the inquest suggested that there were some categories of patients in the emergency
department for whom a senior review is mandatory. It may be that the Trust should wish to
consider whether the circumstances of this case suggest that there are other situations in
which a senior review should be required.”
Group Chief Executive:
Chairman:
As a result of the concerns which were raised by the Coroner, the Trust considered the measures
which could be put in place to ensure that this concern would not be raised again in the future. The
Trust confirmed to the Coroner that the four measures listed below were being considered and so the
Trust has provided the following update on all of the four measures:
:
1. A revision to the Standard Operating Practice to set out who is responsible for
reviewing patients:
An updated Emergency Department (ED) Standard Operating Policy (SOP) ED01 was ratified
on the 28th May 2020 in the Urgent Care Governance Meeting and a copy is enclosed with
this letter. The SOP has been updated to reflect current practice to include the change of
practice to Emergency Department (ED) admitting rights and reference to escalation and
management as defined in the associated SOP ED03. The SOP now has a new expiry date of
February 2022.
The updated SOP clearly reflects who is responsible for each patient within the ED.
The Department medical rota has been changed to increase the number of senior decision
makers present within the department on each day. As a result the number of middle-grade
shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in
the department has been increased by adding a second consultant shift from 15:00 to 22.00
and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely
senior review of patients and will provide consultant ward rounds for EDU.
2. Review of the documentation for admittance to the EDU:
The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU
was located is currently being used as ED Major cubicles which are part of the ED footprint.
When EDU is reinstated post COVID-19 it will have a different location and a new SOP will be
created to reflect this and will take into account the specific risks raised within the PFD report.
The SOP will clearly state which consultant will be responsible for daily ward rounds and
patient ownership will be clearly stipulated. The EDU will not be re-commissioned until the new
SOP is in place.
2
3. Confirmation of which consultant would be responsible for reviewing patients in the
EDU:
Please refer to point 2.
4. Whether the EDU is being permanently removed:
Please refer to point 2.
As the Coroner will note the Trust has taken the necessary steps to address concerns raised. The
Trust would like to offer assurance that the concerns have been actioned and appropriate measures
put in place to avoid a similar incident happening again.
Yours faithfully
Medical Director
3
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