Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0093, written 15 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 | 15 Apr 2020 |
|---|---|
| Reference | 2020-0093 |
| Deceased | Patricia McAdam |
| Coroner | S Ormond-Walshe |
| Coroner area | South London |
| Category | Community health care |
| 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
THIS REPORT IS BEING SENT TO:
|
GP Surgery
Parkway Health Centre
Parkway
New Addington
Croydon
Cr0 OJA
1 CORONER
!am Miss S. Ormond-Walshe, HM Senior Coroner, South London Jurisdiction.
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
On 2nd June 2018 | commenced an investigation into the death of Mrs Patricia Mcadam.
The investigation concluded at the end of the inquest on 13” March 2020. The medical
cause of death was:
ja. Multi-Organ failure
1b. Septic Shock
ic. Infected leg ulcers (with osteomyelitis) and peripheral vascular disease
2. immobility due io rheumaioid arthritis and iow body mass index (cachexis
The conclusion of the inquest was that Patricia Mcadam died suffering sepsis caused by
peripherai vascuiar disease and immobility.
4 CIRCUMSTANCES OF THE DEATH
The deceased was known to be wheelchair bound due to her arthritis and was a smoker
with peripheral vascular disease. She was cared for at home by her daughter. On 31st
May 2018 she was admitted to Croydon University Hospital in a state of extremis. Her
pressure sores and leg ulcers were Grade 4. She died of sepsis eleven days later on 11th
June 2018. Post mortem examinations have identified old rib fractures, which could have
happened with trivial force. There is some evidence that the deceased refused care in the
years preceding her state of extremis in May 2018. She was a frail, elderly lady who had
not seen her GP for a long time and the District Nurses since 2015. There is a natural
causes element to her death, particularly in relation to her arthritis and peripheral vascuiar
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. —
M
n to be wheelchair bound due to arthritis and was a smoker with
ease. She was cared for at home by her daughter. She died at
Sy) eee Cy
pital on 17
peripheral vase.
Sudan tintcoriny EI Shes peti gaya en, Sy ena ae
Croydon University Hi lications associated with infected
leg ulcers.
large
pre
Furosemide) continued despite there being no obvious regular attempt, or any, to assess
and check up on her.
Caring for patients refusing patient care is obviously challenging. However, | am
concerned that there is a system in place in the future to ensure that these patients are
regularly assessed, even if that assessment bears no fruit due to a competent patient
declining help. | am reassured that the GP practice has put into place a system now
whereby these patients do not get forgotten but this report asks for confirmation of such a
system.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and 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 10°” June 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
{ have sent a copy of my report to the Chief Coroner and to the family of Mrs Patricia
Mcadam
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, 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.
915" April 2020 Signed:
Pp
s S Ormond-Walshe
Senior Coroner
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