Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0198, written 5 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2020 |
|---|---|
| Reference | 2020-0198 |
| Deceased | Joan Sanderson |
| Coroner | Alison Mutch |
| Coroner area | Greater 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 i THIS REPORT IS BEING SENT TO: 1) Greater Manchester Health & Social Care Partnership; 2) the Healthcare Safety Investigation Branch 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 2 CORONE~SLEGALPOWERS 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 15th June 2020 I commenced an investigation into the death of Joan Sanderson. The investigation concluded on the 4th September 2020 and the conclusion was one of Narrative: Died from complications of a surgical procedure following an accidental fall. The medical cause of death was 1a) Cardiopulmonary arrest; 1b) MRSA positive left hip metalwork infection; II) Dementia, Diabetes mellitus 4 CIRCUMSTANCES OF THE DEATH Joan Margaret Sanderson had an accidental fall. She was admitted to Tameside General Hospital where a displaced intertrochanteric fracture of the left hip was diagnosed. She was operated on. She developed an infection which was identified as MRSA. She deteriorated and died on 15th June 2020 at Tameside General Hospital. 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. - The inquest heard evidence from the Trust that following her death they had carried out a RCA to understand what learning could be taken from Mrs Sanderson's death. A key piece of learning was identified, as patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result should have a routine swab sent for MRSA on admission to hospital. In this case a swab was not collected as that was not standard at that time. Surgery would not be held up awaiting the outcome but it would have allowed earlier identification of MRSA which could impact the outcome in another case where emergency surgery is required and there is an infection post operatively. Patients admitted for elective surgery have a MRSA swab collected 12 weeks prior and receive decolonisation treatment for a positive MRSA result prior to surgery. The inquest was told this change had been rolled out in the trust and was seen as wider learning that could prevent future deaths within the NHS. 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 30th 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 namely Mr deceased, and Tameside General Hospital, who may find it useful or of interest. son 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. 2 9 Alison Mutch HM Senior Coroner 05.10.2020 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.
AUTHORITY in Greater Manchester Greater Manchester Health and Social Care Partnership Ath Floor 3 Piccadilly Place London Road Manchester M1 3BN Date: 19 November 2020 Ms A Mutch OBE HM Senior Coroner Coroner's. Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths —- Joan Margaret Sanderson 15.06.2020 Thank you for your Regulation 28 Report dated 5 October 2020 concerning the death of Joan Margaret Sanderson on 15 June 2020. Firstly, | would like to express my deep condolences to Joan Margaret Sanderson's family. The inquest concluded that Joan Margaret Sanderson's death was a result of 1a) cardiopulmonary arrest; 1b) MRSA positive left hip metalwork infection; 2) Dementia, Diabetes mellitus. Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding that there was no requirement for MRSA swabbing of patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result. Whilst surgery would not have been delayed awaiting the outcome of results, it could impact the outcome in another case where emergency surgery is required and there is an infection post-operatively. | have noted that your Regulation 28 letter has also been sent to HSIB and | will leave it to the named respondent to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP. Greater Manchester Health and Social Care Partnership is made up of all the NHS arganssations and councils in the city region. We're overseeing devolutian and taking charge of the £6bn health and social care budget. www.gmhsc.org.uk Summary of actions taken or being taken by the organisation involved. The Trust confirmed that; 1. The MRSA Policy was updated in February 2019 to align with national screening guidance around MRSA screening of patients from other hospitals, nursing/residential homes, or those that have had a previous positive screen/clinical sample result on admission is undertaken. Actions taken or being taken to prevent reoccurrence across Greater Manchester. 1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE. 2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission 3. Learning to be shared with the Greater Manchester Infection Prevention and Control Collaborative for members to take into their provider organisations to ensure that national screening guidance is being followed. Findings to be also shared with the Northwest NHS England/improvement infection prevention for consideration of sharing across the Northwest The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice. | hope this response provides the relevant assurances you require. 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 Chair of GM Medical Executive, GMHSCP Greater Manchester Health and Social Care Partnership is made up of all the NHS organisations and councils in the city region. We're overseeing devolution and taking charge of the £6bn health and social care budget. www.gmhsc.org.uk HSIB 27 November 2020 HSib, aa Alison Mutch OBE Cody Technology Park HM Senior Coroner Farnborough Coroner's Court Hampshire 1 Mount Tabor Street gui401x Stockport SK1 3AG Dear Ms Mutch, RE: Regulation 28: Report To Prevent Future Deaths. The death of Joan Margaret Sanderson on 15 June 2020 Thank you for contacting HSIB regarding a prevention of future deaths report regarding Joan Margaret Sanderson dated 5 October 2020. Following careful consideration, we will not be taking forward an investigation into your concerns. We are only able to undertake a limited number of national investigations each year, and therefore try to focus on those with the most potential for new learning across the NHS. The National Criteria for selection is described on our website: httos://www.hsib.org.uk/public-patients/how-we-decide- to-investiqate/ We do not underestimate the seriousness of your concerns and may consider this issue again in the future as further information becomes available. The information that you have shared with us is important, even if we do not start an investigation as a result. Everything we receive is added to our database, whether we start an investigation or not. As it grows, our database builds a picture of risk in healthcare and allows us to identify recurring problems and patterns. Should we wish to contact you in the future regarding this information, it would help if we store the personal details you have given us, if this is acceptable to you. If you prefer that we do not keep your details, please let us know and we will ensure that they are removed from our database in accordance with our privacy notice (httos://Awww.hsib.org.uk/privacy/). Once again, thank you for contacting us and we are sorry that we are not able to take this forward. Yours sincerely, Chief Investigator SS !,!7 CNOUIRIES aHSIS.ORG.UK | WWW.HSIS.ORG.UIK ae)
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.