Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0146, written 30 Jul 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2020 |
|---|---|
| Reference | 2020-0146 |
| Deceased | Reginald Collins |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Minister of State for Social Care, Greater Manchester Health and Social Care Partnership 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 25th October 2019 I commenced an investigation into the death of Reginald Collins. The investigation concluded on the 10th July 2020 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Aspiration pneumonia on a background of immobility; 1b) Fracture neck of femur following a fall; and II) Ischaemic heart disease, Frailty 4 CIRCUMSTANCES OF THE DEATH Reginald Collins fell and fractured his neck of femur at The Meadows (Saffron Ward). He was admitted to Stepping Hill Hospital on 13th September and on 14th September he was operated on. He was medically optimised by 19th September 2019. Discharge was delayed due to a suitable placement not being available due to his complex needs. He developed aspiration pneumonia and deteriorated and died at Stepping Hill Hospital on 22nd October 2019. 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. – 1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd 1 October because of the challenges of finding a suitable EMI placement for him. 2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not. 3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally. 4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 24th September 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 the following Interested Persons, namely Mrs deceased, who may find it useful or of interest. wife of the 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 Alison Mutch OBE HM Senior Coroner 30.07.2020 2 3
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.
Greater Manchester Health and Social Care Partnership BY EMAIL T: E: @nhs.net Date: 4th November 2020 Ref: To: Alison Mutch OBE HM Senior Coroner HM Coroner’s Office, 1 Mount Tabor Street Stockport, SK1 3AG Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Reginald Collins, date of death 22nd October 2019 Thank you for your Regulation 28 Report concerning the death of Mr Collins on 22nd October 2019. Firstly, I would like to express my deep condolences to Mr Collin’s family. The regulation 28 report concludes Mr Collin’s death was a result of 1a) Aspiration pneumonia on a background of immobility; 1b) Fracture neck of femur following a fall; and II) Ischaemic heart disease, Frailty Following the inquest you raised concerns in your Regulation 28 Report to NHS England; that 1. The inquest heard that Mr Collins could have been discharged on 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him. 2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not. 3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally . 4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust. From the discussion with Stockport Council, the Local Authority Director of Adult Services (DASS) and commissioners, it appears that the Local Authority has not had the opportunity to respond to the coroner on this specific event and thus not had sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly ( @stockport.gov.uk). As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place. The huge pressures on Trusts is fully acknowledged and we continue to support and drive the ‘Home First’ approach as evidenced in the majority of work including our Living Well at Home Programme here in GM. I hope this information is to your satisfaction and please do not hesitate to contact me if you need any further information. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Dr Chair of GM Medical Executive, GM HSCP
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