Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0254, written 26 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 | 26 Nov 2020 |
|---|---|
| Reference | 2020-0254 |
| Deceased | Eleanor Sherman |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Community health care · 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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive Warwick Hospital
2. M rs-
3. Chief Coroner
CORONER
I am S McGovern, Senior Coroner, for the Coroner area of Warw1cksh1re
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 (lnvest1gat1ons) Regulations 2013
[HYPERLINKS]
3
INVESTIGATION and INQUEST
On 1st September 2020 I commenced an invest1gat1on into the death of Eleanor Emily
SHERMAN 72 years old The invest1gat1on concluded at the end of the inquest on 25
November 2020 The conclusion of the inquest was a Narrative Verdict
Mrs Sherman was a woman of 72 years who died on 20 August 2020 at Warwick
Hospital.
Mrs Sherman's cause of death was determined by a post mortem examination to be la
Subarachno1d and lntracerebellar Haemorrhage lb Systemic Hypertension.
On 13 August 2020, Mrs Sherman contacted her GP by telephone. He was concerned
about her symptoms and referred her to the Ambulatory Emergency Centre{AEC) at
Warwick Hospital. The GP telephoned the hospital and indicated that Mrs Sherman
needed a scan to exclude a subarachno1d haemorrhage {SAH). He also emailed a
referral letter expl1c1tly stating that Mrs Sherman's presentation should be considered a
SAH until proven otherwise. She was m1sd1agnosed and discharged without a scan.
Neither the notes of the GP's telephone call nor the GP's email were seen by the
treating staff except for final doctor who saw her 1mmed1ately prior to discharge.
On 15 August 2020, Mrs Sherman re-attended Warwick Hospital. She was seen by a
doctor in Emergency Department. He did not have access to the GP's letter or notes
from the attendance on 13th August 2020. The discharge summary from 13th August
2020 would have been available but medical staff were unaware of this. Mrs Shem a n's
symptoms were unchanged from her earlier attendance
On 20th August 2020, Mrs Sherman suddenly collapsed at home and was brought to
Warwick Hospital by ambulance. A CT scan performed at 15.41 hours confirmed a SAH.
She died later that day.
The clinical errors (two m1sd1agnoses and failure to read GP referral letter) and
systemic errors (GP referral letter and AEC notes not available on 15th August 2020)
contributed to her death and constitute neglect notwithstanding her presentation of
SAH was atypical.
4
CIRCUMSTANCES OF THE DEATH
See above
5
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters g1v1ng nse to concern In
my opinion there 1s a nsk that future deaths could occur unless action 1s taken In the
circumstances 1t 1s my statutory duty to report to you
The MATTERS OF CONCERN are as follows -
(1) Two m1sd1agnoses at Warwick Hospital notwithstanding the GP spec1f1cally
stating in writing that Mrs Sherman should be treated as a SAH unless a CT
scan showed to the contrary
(2) Systemic errors regarding the inab1l1ty of the GP team at Warwick Hospital to
access the electronic record and the slowness of notes being scanned on to the
system.
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 w1th1n 56 days of the date of this report,
namely by 21 January 2021
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 1s proposed
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons Mrs
(daughter)
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it
I may also send a copy of your response to any other person who I believe may find 1t
useful or of interest
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 1t 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
9
26 November 2020
S. McGovern
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.
Our ref: i INHS| Wednesday 20 January 2021 South Warwickshire NHS Foundation Trust Mr Sean McGovern Senior Coroner for the Coventry and Warwickshire Area Chief Executive The Coroner's Office a es Warwickshire Justice Centre Warwick Newbold Terrace CV34 5BW Leamington Spa Te Warwickshire ana 2X CV32 4EL Email: Po PRIVATE AND CONFIDENTIAL Dear Mr MoGovéin, Se an~ | Regulation 28 report — Mrs Eleanor Sherman DoB 12/04/1948 DoD 25/11/2020 Thank you for your Regulation 28 report dated 26" November 2020 relating to the inquest of Mrs Eleanor Sherman. | was sorry to read of your outstanding concerns at the conclusion of the inquest and hope that the following information will provide you with further reassurance. Following receipt of your report, the Trust convened a Working Group to review and critically reappraise the care and decision-making related to Mrs Sherman. That Group included our Medical Director, Director of Nursing, Head of Governance, a number of consultant physicians from both the Emergency Department (ED) and the Acute Medical Unit (AMU) and senior clinical nursing staff within ED. The Group explored, and reflected upon, a number of points relating to Mrs Sherman's care including the adequacy of the actions arising from the Trust's Root Cause Analysis (RCA) Investigation that were outlined at the Inquest. An updated position on the actions listed in the Action Plan of the RCA Investigation can be found below but | can confirm that the actions outstanding at the time of the inquest have all now been completed. In addition to these existing actions, the Working Group felt that there should be a Trust-wide, rather than just ED/ AMU, dissemination of the revised Acute Headache Pathway to ensure that the wider Trust clinical body was aware of it. To this end, the Pathway has also not only been disseminated via Acute Medical Admission’s own intranet page, but also introduced via the Trust-wide Patient Safety Newsletter. It is now available for all staff to refer to on the Trust's intranet site. Separately to reviewing organisational learning from this case the Trust’s Medical Director has reviewed any previous clinical incidents that the consultant practitioner was involved in and has discussed his performance with his clinical director. The Medical Director has met with NHS Resolution, the General Medical Council’s Employment Liaison Advisor and the practitioner, and has agreed with the clinical director a plan for the consultant practitioner's development in the light of this incident. Cha Chief eas The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Although our RCA Investigation of Mrs Sherman’s care highlighted a number of care management concerns which have now been addressed, | am grateful that your Regulation 28 Report provided us with a further opportunity to consider and improve our care to patients with symptoms suggestive of subarachnoid haemorrhage. The latest position on all of the actions arising from both our RCA Investigation and the further review arising from your Regulation 28 Report can be found at the foot of this letter. | hope that this provides you with the assurance that you require but if, having read this letter, you have outstanding concerns, please do not hesitate to contact me. Yours sincerely Se Chief Executive Action ref 10675 Action 1. Grant Access to GPs in ED to e-records (Evolve) and Lorenzo - DIWIT, GPs to complete e-learning module on e-records (Evolve) and Lorenzo software Action Lead(s) 01/12/2020 Completed jone date 11/01/2021 10676 2. Subarachnoid haemorrhage to be discussed as part of the Junior doctors teaching program with this case to be incorporated into Junior doctors teaching and handbook to share learning 31/01/2021 Completed 04/11/2020 10678 3. Doctors involved to reflect on the case and review NICE guidelines on headache. Junior staff to discuss it with their educational supervisor noting it on their Form R and appraisals. 31/01/2021 Completed 25/11/2020 10679 4. Learning from incident to be shared with staff working in AEC and ED via team meetings and newsletters 10680 5. Amendment of the ACP Triage Form to include GP concerns and re-design of the form used by MNPs in AEC to take down GP referrals Consideration to be given to whether this form part of the medical record and to ensure it is included where appropriate. 30/11/2020 Completed 11/11/2020 30/11/2020 Completed 13/10/2020 10682 6. Review processes within AEC to ensure referral letters are available and seen by Doctors prior to seeing the patient. 30/11/2020 Completed 15/10/2020 10681 7. Medical team to review processes to ensure improved access to AEC notes for ED staff, including considering real time scanning and making ED aware of AEC note location for re-presenters 31/01/2021 Completed 20/11/2020 10683 8. Awareness raising with ED staff to ensure they are aware that AEC discharge summaries are available immediately after the AEC visit on Lorenzo within the individual patient record (Letters tab on right hand side) 30/11/2020 Completed 20/11/2020 10684 9. Develop an Acute Headache pathway - ED and Acute Medicine to develop an SOP for the assessment and management of acute severe headache incorporating the Ottowa subarachnoid decision tool. 30/04/2021 Completed 03/12/2020 Chair: fs Chief Executive The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process.
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