Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0172, written 8 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Sep 2020 |
|---|---|
| Reference | 2020-0172 |
| Deceased | Linda Phillipson |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Western Sussex Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
VERONICA HAMI LT ON -DEELEY DL, LLB. Her Majesty ' s Seni or Coroner for the C ity of Brighton & Hove TH E CORON ER 'S OFFI CE WOODY ALE, LEW ES ROAD BRI GHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Dame Trust 2. Mr - 3. Mr. CORONER Chief Executive, Western Sussex Hospital - Chief of Service, Western Sussex Hospital Trust Trauma & Orthopaedic Surgeon I am Veronica HAMIL TON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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. INVESTIGATION and INQUEST On 1ih December 2019 I commenced an investigation into the death of Linda Ann PHILLIPSON The investigation concluded at the end of the inquest on 2nd September 2020.The conclusion of the inquest was MEDICAL MISADVENTURE BEING MAJOR PULMONARY EMBOLISM DURING SURGERY FOR A COMPLICATED TIBIAL FRACTURE ON A BACKGROUND OF UNNECESSARY DELAYED EXTERNAL FIXATOR AND SUBOPTIMAL CARE BOTH LEADING TO INCREASED IMMOBILITY BEFORE TRANSFER TO THE SOUTH EAST TRAUMA CENTRE CIRCUMSTANCES OF THE DEATH See Record of Inquest CORONER'S CONCERNS During the course of the inquest the evidence revealed matters rise to 1 2 3 4 5 VERON IC A HA M ILT ON-DEELEY DL, LL.B. Her Maj esty ' s Senior Coroner for the City of Brighton & Hove THE CO RON ER ' S OFFICE WOODVA LE, LEWES ROA D BRIG HTON BN23 QB Tel ephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 6 7 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 delay in applying the external fixator (2) The apparent failure to mobilize the patient ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND your organisation have the power to take such action . YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th November 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 1.Mr. - 2 . Brig~ 3. Secretary of State for Health, Department of Health 4. Simon Stevens, Chief Executive, NHS England niversity Hospital Trust I have also sent it to :- 1. Dr 2. Mr. 3. Mr. CCG , Head of Quality and Nursing CCG - Chief Executive CQC Who may find it useful or of interest. 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. 2 VERONICA HAMIL TON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the Ci ty of Brighton & Hove THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB Telephone : Brighton (01273) 292046 Fax: Brighton (01273) 292047 9 Date: 8th September 2020 SIGNED BY: ·• . v· ,~(lUl,M/(tY\v ~-JJ_,~,fr:~i Senior Coroner Brighto~ 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.
INHS| Western Sussex Hospitals NHS Foundation Trust Worthing Hospital Lyndhurst Road, Worthing West Sussex; BN11 2DH Tel: 01903 205111 www.westernsussexhospitals.nhs.uk 20" November 2020 Mrs Veronica Hamilton-Deeley Senior Coroner for Brighton & Hove Coroner’s Office Woodvale Lewes Road Brighton BN2 3 QB Dear Mrs Veronica Hamilton-Deeley Re: Regulation 28 Report ~ Mrs Linda Phillipson Thank you for your letter dated 8" September 2019 which included a formal copy of the Regulation 28 report to Prevent Future Deaths. The Trust welcomes the opportunity to review the way that patients who sustain trauma are managed. As part of this process, the PFD report has been shared with the Trauma and Orthopaedic Consultants, Radiologists, Physiotherapists, ward nurses and through teaching with the junior doctors on both sites of the Trust. It has also been discussed at the Trust Trauma and Orthopaedic Clinical Governance meeting and a further thorough RCA been conducted which will be shared with Mrs Linda Phillipson’s family and Sussex Traurna Network Consultants. We can confirm that a Trust Surgical Board ratified Transfer Policy has been put in place between Brighton & Sussex University Hospitals and Western Sussex Hospitals NHS Foundation Trust hospitals for the management of complex trauma patients who need specialist surgery at the Major Trauma Centre. The immediate management of major trauma in Western Sussex Hospitals whilst awaiting transfer is included within the transfer protocol. The application of spanning external fixator for all Peri-articular complex fractures, elevation and early mobilisation with physiotherapists has been also included within the protocol to prevent any further similar occurrence. Further to this, there are also plans for regular Educational and Clinical Governance meetings between Brighton & Sussex University Hospitals, Eastern Sussex Hospitals NHS Trust and Western Sussex Hospitals for complex trauma management beginning from January 2021. Mrs Phillipson’s CT scan findings were also discussed at Radiology Events and Learning meetings (REALM, formerly discrepancy meeting) to all radiologists in the department and the learning from this shared. The Trust was saddened by Mrs Linda Phillipson’s death and would like to give our reassurance that the Trust has taken the opportunity to review our current practice to ensure we manage patients who have sustained major trauma in the most safe and effective way. Yours tours Sinus Mone Director
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