Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0089, written 3 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Apr 2020 |
|---|---|
| Reference | 2020-0089 |
| Deceased | Andrew Wing |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: ANDREW SPENCER WING __________________________________________________________ The Inquest Touching the Death of Andrew Spencer Wing A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: Dr Katherine Henderson, President of the Royal College of Emergency Medicine Dame Clare Marx Chair of the General Medical Council Sue Webb, President of the College and Society of Radiographers 1 CORONER Caroline Topping HM Assistant Coroner, for the County of Surrey 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 An inquest into the death of Andrew Spencer Wing was opened on 23rd May 2019 and resumed on the 2nd April 2020 and concluded on 6th March 2020 I concluded with a narrative conclusion that: Andrew Wing suffered an acute onset of pain in his chest at 1am on the 13th January 2019. He attended at St Peter’s Hospital, Chertsey at 16.47 where he was seen in the minor injuries department by which time his pain had diminished and presented as mild. He underwent investigations which ruled out a myocardial infarction. An aortic dissection was one of the differential diagnoses the possibility of which was recognised and for which the necessary diagnostic investigation was a CT Aorta. Despite the index of suspicion being sufficient to require this to be undertaken it was not and had it been it would have identified an aortic dissection. He was discharged and died from the effects of the aortic dissection on the 15th January 2019 at the Ship Hotel in Weybridge. Had a dissection been identified on the 13th January 2019 prior to discharge he would have been subject to the necessary emergency surgery which he would have survived. The cause of death was : 1a Haemopericardium 1b Aortic Dissection 1c Hypertension I concluded with the narrative conclusion set out above. 4 CIRCUMSTANCES OF THE DEATH Andrew Wing had a long history of untreated hypertension having refused medication for the condition. In the early hours of the 13th January 2019 he suffered an acute onset of severe pain in his left side. He attended St Peter’s Hospital, Chertsey by which time the pain had diminished. He underwent investigations, an ECG, Chest Xray and blood tests. The blood tests did not show a rise in troponin levels. The Chest Xray was read by 2 emergency clinicians who thought it appeared normal. He was discharged from hospital and died on the 15th January 2020 from the effects of the aortic dissection. Aortic dissection was one of the differential diagnoses considered but a CT Aorta was not undertaken. 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 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. – The evidence showed that: 1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken. 2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 29th May 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; St Peter’s Hospital, Chertsey. 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 Signed: Caroline Topping Dated this 3rd April 2020.
2 responses 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.
From the Chief Executive and Registrar 27 May 2020 Miss Caroline Topping HM Coroner's Court Station Approach Woki ng GU22 7AP Dear Miss Topping General Medical Council Regent's Place 350 Euston Road London NW1 3JN Email: gmc@gmc-uk.org Website: www.gmc-uk.org Telephone: 0161 923 6602 Chair Dame Clare Marx Chief Executive and Registrar Charlie Massey Mr Andrew Spencer Wing (Deceased) I am writi ng to you following receipt of the Regulation 28 Report dated 3 Apri l 2020. I am sorry to hear about the death of Mr Andrew Spencer Wing and I am grateful to you for bringing this to my attention. I have noted the contents of the report and have forwarded this matter to our Employer Liaison Adviser to discuss with the Trust. If the Trust identify any individual cl inicians whose fitness to practise may be impaired, they will refer to us to consider in line with our usual procedures. Please do feel free to contact me if you would like to discuss this further. Yours sincerely Charlie Massey
Chief Executive Officer Richard Evans OBE Ms Caroline Topping HM Assistant Coroner for the County of Surrey By email to: Dear Ms Topping Re Regulation 28 Report: Andrew Spencer Wing Thank you for contacting the Society of Radiographers (SoR) in connection with the inquest following the death of Andrew Spencer Wing, concluded on 6th March this year. I am the current President of the SoR, having taken over the role from in July 2019. We note your concerns that appropriate actions might help avoid future deaths in similar circumstances. The SoR is pleased to provide the following perspectives and actions. The Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 17) is the legislative framework governing all clinical imaging that uses x-rays. The regulations stipulate the legal requirements for all aspects of any x-ray procedure, including the responsibilities surrounding referral of a patient for imaging. In the case of Mr Wing, the clinician that referred him for the chest x-ray should have been aware of the requirements to provide sufficient clinical information to justify the procedure and to enable a diagnostic report to be subsequently made. The employer has an over-arching responsibility to ensure all referrers within their authority are trained in the requirements of IR(ME)R 17. From your report it seems likely that the referral for Mr Wing to have a chest x-ray did not include the details of the differential diagnosis of dissecting aortic aneurysm. Had these details been included, the radiographers involved in taking the chest x-ray and in providing the clinical report could have recommended further imaging, including the CT scan which could have provided a more definitive diagnosis. The SoR works in partnership with the Royal College of Radiologists and the Institute of Physics and Engineering in Medicine to promote understanding of IR(ME)R 17. We do this through a collaborative body, the Clinical Imaging Board. New guidance is currently in preparation and is expected to be approved in the near future. This will include the responsibilities of employers and referrers under the legislation. The following extract is from an advanced draft: Referrer The referrer must be a registered healthcare professional (10) as defined in IR(ME)R. In Northern Ireland, this also includes medical practitioners registered with the Medical Council of Ireland. Quartz House, 207 Providence Square, Mill Street, London SE1 2EW T: 0207 740 7200 E: info@sor.org W: www.sor.org The Society of Radiographers is a company limited by guarantee registered in England under No. 169483 Registered Office: 207 Providence Square, Mill Street, London SE1 2EW
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