Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0229, written 10 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 | 10 Nov 2020 |
|---|---|
| Reference | 2020-0229 |
| Deceased | Leslie Clewarth |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid Yorkshire Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Mid Yorkshire Hospitals NHS Trust
1 | CORONER
lam Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (E).
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 23/04/20 | commenced an investigation into the death of Leslie Clewarth aged 86.
The investigation concluded at the end of the Inquest on 06/11/20.
The Inquest reached a narrative conclusion to the effect that Leslie Clewarth died in
hospital from natural causes: 1a. aspiration pneumonia, ib. small bowel obstruction 1c.
adhesions within the peritoneal cavity and Il. ischaemic heart disease.
4 | CIRCUMSTANCES OF THE DEATH
The family of Mr Clewarth were called before 7am on 07/04/20 due to the deterioration
in his condition. They were permitted to remain at his bedside throughout the day,
notwithstanding the COVID19 visiting restrictions then in force.
Concerns were raised by his daughter and her husband in relation to:
(1) The NG tube previously inserted was no longer in place.
(2) The syringe driver was empty at some point after 4pm that day. In consequence,
he was deprived of essential medication and hence died in agony after choking
on faecal material aspirated.
{3) After he had died an injection of Buscopan was made.
(4) He had not been treated for a severe coronary condition despite being in
hospital for many weeks.
Medical records which should have documented these matters were missing or
inadequate.
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) Without adequate records showing the care provided or dosage administered, it
was not possible to corroborate the testimony of nurses who had attended to Mr
Clewarth on the afternoon he died. This fuelled the suspicions raised by his
daughter and her husband.
(2) Drugs which were left unused after Mr Clewarth’s death were not accounted for.
Without proper records there is a risk that essential care may not be provided or is
erroneously duplicated, thus potentially putting a patient's safety or health at risk.
ACTION SHOULD BE TAKEN
in my opinion action should be taken to prevent future deaths and [ believe your
organisation has 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 15 January 2021. | have extended this period on account of the ongoing
COVID crisis and the forthcoming holidays.
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.
COPIES and PUBLICATION
| have sent_a copy of my report to the Chief Coroner and to the following Interested
lam 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.
10th November 2020 7 1
Kec Mey —— Sane Co tanert
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.
Your ref:
Our ref:
Date: 13 January 2021
Mr K McLoughlin
Senior Coroner
Coroner’s Office and Court
71 Northgate
Wakefield
WF1 3BS
Dear Mr McLoughlin
Medical Director
Trust Headquarters and Medical Education Centre
Aberford Road
Wakefield
WF1 4DG
PA:
Re: Inquest touching the death of Leslie Clewarth (deceased)
I am responding on behalf of the Trust to the Regulation 28 Report to Prevent Future
Deaths issued by yourself to The Mid Yorkshire Hospitals NHS Trust on 10th November
2020.
The Matters of Concern raised in your report were: -
1) Without adequate records showing the care provided or dosage administered, it
was not possible to corroborate the testimony of nurses who had attended to Mr
C on the afternoon he died. This fuelled the suspicions raised by his daughter
and her husband.
2) Drugs which were left unused after Mr C’s death were not accounted for
Without proper records there is a risk that essential care may not be provided or is
erroneously duplicated, thus potentially putting a patient’s safety of health at risk.
I would like to thank you for bringing these matters to our attention. I absolutely agree
that clear documentation is key to ensuring patient safety.
In order to respond to this Regulation 28 notice we have taken the opportunity to review
our Trust Syringe Pump Policy, the Trust Syringe Pump combined prescription and
administration chart and the relevant sections of our Trust Medicines Management
Policy. In addition we have audited 10 cases from gate 34 where patients were having
medication administered via a syringe pump that was subsequently discontinued at the
end of their life against the syringe pump policy.
Chairman –
Chief Executive –
In light of the above reviews we have determined that the syringe pump policy and the
prescription / administration chart should be revised to provide clearer guidance and
support better adherence to the policy. In particular this relates to the recording of any
medication remaining in the syringe at each check and the amount discarded at the
change or end of the use of the syringe driver and a prompt to support staff in
recognising when the next syringe change will be required. Once the revised policies
have gone through the appropriate governance routes in the Trust there will be further
training delivered to support their use.
Once again thank you for bringing these matters to our attention.
Yours sincerely
Medical Director
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