Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0221, written 3 Nov 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 Nov 2020 |
|---|---|
| Reference | 2020-0221 |
| Deceased | Clara Moniatis |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Barts and Whipps trust 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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 15 May 2019 I commenced an investigation into the death of Clara Iris Moniatis.. The investigation concluded at the end of the inquest on 7 October 2020. The conclusion of the inquest was:- Clara Iris Moniatis had been unwell for some days and on the morning of 5 May 2019 she was taken to the Emergency Department of Whipps Cross Hospital. Despite medical treatment, she died there at 18.56pm that evening. She died of Natural Causes. 4 CIRCUMSTANCES OF THE DEATH The cause of death was 1a) dilated cardiomyopathy. This condition had been previously undiagnosed Please see above 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 matter of waiting times from chest x-ray to the review of the imaging 2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you and your 1 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 18th December 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- solicitors for the family 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 3 November 2020 Caroline Beasley-Murray 2
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.
16 December 2020 PRIVATE & CONFIDENTIAL Ms Caroline Beasley-Murray HM Senior Coroner Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Telephone: Chief Medical Officer Dear Ms Beasley-Murray RE: Regulation 28: Report to Prevent Future Deaths www.bartshealth.nhs.uk I write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding the care of Clara Moniatis. Clara, a 5 month old child, was bought to the Whipps Cross Hospital (WCH) Emergency Department (ED) by her parents with worsening symptoms of possible tonsillitis. Having been clinically stable, Clara deteriorated rapidly after 5 hours in the department and arrested, resuscitation was unsuccessful. Post mortem examination identified previously undiagnosed dilated cardiomyopathy. The matters of concern raised in the Regulation 28 notice were: 1. The matter of waiting times from chest x-ray to the review of the imaging 2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review We have previously noted that the documented timings of x-ray review represent a maximum time, as notes are often made in retrospect within a busy emergency department. Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff. Yours sincerely Chief Medical Officer Barts Health NHS Trust
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