Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0269, written 2 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2020 |
|---|---|
| Reference | 2020-0269 |
| Deceased | Ivan O’Neill |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MISS N PERSAUD SENIOR CORONER EAST LONDON Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1 H 0EU 2. Chief Executive, Barts Health NHS Trust, Royal London hapel Road, London, E11BB Email: CORONER I am Graeme Irvine, Area Coroner for the coroner area of East London 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. http:ljwww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/ uksi/2013/ 1629/part/ 7 / made 3 INVESTIGATION and INQUEST On 22nd April 2020 I commenced an investigation into the death of Ivan Merryfield O'Neill aged 74 years. The investigation concluded at the end of the inquest on 20th November 2020. The conclusion of the inquest was a narrative conclusion: "On 21st April 2020 Mr Ivan Merryfield O'Neill attended hospital for dialysis. An accidental dislodgement ofa venous needle that takes blood under pressure to the dialysis machine occurred, which led to a significant bleed. Staffon the unit were unaware ofthe bleed, until an alarm from the dialysis machine sounded due to a drop in pressure. Mr O'Neill was.found to be unres onsive 1 having sustained a cardiac arrest due to hypovolemic shock, despite resuscitation attempts his life was pronounced extinct at 09.30 hours." The cause of death was recorded as; 1a; Hypovolemic Shock 1 b; End-Stage Kidney Disease II; Polyneuropathy, Frailty and COVID 19 4 CIRCUMSTANCES OF THE DEATH During a regular dialysis appointment, Mr O'Neill bled to death when a venous needle became dislodged from the site ofhis arteriovenous fistula. 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 could 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. Mr O'Neill was known to be a restless patient during a dialysis session. This factor must have increased the risk of needle dislodgement. 2. Mr O'Neill was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed. 3. Mr O'Neill was placed in a position which was outside of a clear line of sight from the nurses station. 4. The automatic alarm triggered by the dialysis equipment was insufficiently sensitive to promptly alert staff to a bleed until between 200 - 2000 mls of blood had already been lost. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th 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 is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr O'Neill and the CQC. I have also sent it to the Director of Public Health who may find it useful or of interest. 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 it useful or of interest. 1 2 The Chief Coroner may publish either or both in a c~plete or redacted or summary form. He may send a copy of this report to any per bh who he believes may find it useful or of interest. • l You may make representations to me, the corone at the time of your response, about the release or the publication of your response. / I 9 2nd December 2020 - 3
See every Prevention of Future Deaths report matching Barts Health NHS Trust, 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.