Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0023, written 1 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Feb 2021 |
|---|---|
| Reference | 2021-0023 |
| Deceased | Betty Tadman |
| Coroner | Sonia Hayes |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Medway NHS Foundation 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: 1. Chief Executive Medway NHS Foundation Trust 1 CORONER I am Sonia Hayes assistant coroner, for the coroner area of Mid Kent & Medway 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://www.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 19thNovember 2018 an investigation was commenced into the death of BETTY I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 ANNIE TADMAN. The investigation concluded at the end of the inquest on 21st and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. January 2021. The conclusion of the inquest was Fall Causing Pelvic Fracture with http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 Extensive Local Haemorrhage 2 Haemorrhagic Cystitis and Gastritis, Dalteparin http://www.legislation.gov.uk/uksi/2013/1629/part/7/made administration for suspected Deep Vein Thrombosis a Narrative. 4 CIRCUMSTANCES OF THE DEATH Betty Tadman died on 3rd November 2018 as a result of a fall at home on 2nd November 2018 that caused a pelvic fracture with extensive local haemorrhage. The fall was unwitnessed but likely occurred when Betty tangled her walking stick in her trouser leg. She was conveyed to hospital with a pre-alert for sepsis. She was unable to weight bear and her left leg was noted to be shortened, no scan or X-ray was conducted. Betty was treated for suspected urosepsis and also deep vein thrombosis with therapeutic dalteparin and continue to deteriorate. There was a missed opportunity to diagnose a pelvic fracture with internal bleeding that contributed to her death. It is unlikely Betty would have survived surgical intervention. 1 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. Mrs Tadman had dementia and a long-term catheter who was admitted to hospital with a pre-alert for suspicion for urosepsis that was treated appropriately. However, urine dipstick tests were only positive for blood and consideration was not given to the circumstances in which she was found with a history of a fall. 2. Evidence was heard at the inquest that ambulance crew noted and handed over Mrs Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury. 3. Mrs Tadman was an elderly lady with a medical history of osteoporosis who fell from a standing height. No imaging was conducted on admission to hospital to establish if Mrs Tadman had sustained an injury. 4. Swelling in the calves gave rise to a suspicion of potential deep vein thrombosis and dalteparin was prescribed. Physical examination was over reliant on the lack of complaints of pain in a patient with dementia in the absence of imaging. 5. There was no consideration of potential fracture or internal bleeding in the presence of dropping of haemoglobin and continued deterioration. 6. The Trust did not conduct a serious incident investigation following Mrs Tadman’s death when the post-mortem cause of death established a pelvic fracture with severe haemorrhage. Evidence heard at the inquest confirmed that this case was not discussed at the trust morbidity and mortality review or any other forum giving rise to concerns that lessons had not been learned. 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. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28th March 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 (daughter). 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 Signature: Sonia Hayes Assistant Coroner Mid Kent & Medway 1st February 2021 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.
MEDICAL DIRECTORS OFFICE
PRIVATE & CONFIDENTIAL
Ms Patricia Harding
Senior Coroner for Mid Kent and Medway
Kent Register Office
The Archbishop’s Palace, Palace Gardens
Mill Street
Maidstone, Kent
ME15 6YE
Dear Ms Harding,
Medway Maritime Hospital
Windmill Road
Gillingham
Kent
ME7 5NY
Regulation 28 Report to Prevent Future Deaths – Betty Tadman
We now respond to the Assistant Coroner’s concerns set out in the Regulation 28 Notice dated
1st February 2021. The events took place in early November 2018 and the Trust is committed to
sharing any learning which arose from the events and the inquest heard on 21 January 2021, as
set out below.
1. Coroner’s Matters of Concern
1.1. Mrs Tadman had dementia and a long term catheter and was admitted to hospital with a
pre-alert for suspicion for urosepsis that was treated appropriately. However, urine dipstick
tests were only positive for blood and consideration was not given to the circumstances in
which she was found with a history of a fall.
1.2. Evidence was heard at the Inquest that ambulance crew noted and handed over that Mrs
Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise
to use the commode in hospital. No consideration was given to a potential fracture
injury.(The Trust wishes to point out that in fact the ambulance record documented
shortening but no rotation)
1.3. Mrs Tadman was an elderly lady with a medical history of osteoporosis who fell from a
standing height. No imaging was conducted on admission to hospital to establish if Mrs
Tadman had sustained an injury.
1.4. Swelling in the calves gave rise to a suspicion of potential deep vein thrombosis and
Dalteparin was prescribed. Physical examination was over reliant on the lack of complaints
of pain in a patient with dementia in the absence of imaging.
1.5. There was not consideration of potential fracture or internal bleeding in the presence of
dropping of haemoglobin and continued deterioration.
1.6. The Trust did not conduct a serious incident investigation following Mrs Tadman’s death
when the post mortem cause of death established a pelvic fracture with severe
haemorrhage. Evidence heard at the Inquest confirmed that this case was not discussed at
the Trust’s morbidity and mortality review or any other forum giving rise to concerns that
lessons had not been learned.
2. Trust Response to points 1.1-1.5
2.1. The Trust accepts there were multiple opportunities where symptoms of a traumatic injury
and occult haemorrhage were missed despite repeated blood tests showing a decreasing
haemoglobin level. These appear to be at individual nursing and medical assessments
which failed to consider a differential diagnosis as the clinical focus was on possible uro-
sepsis and DVT symptoms. There was an incorrect interpretation of the D-Dimer test which
could have also been explained by an undiagnosed fracture and haemorrhage. The vast
majority of pelvic fractures are managed conservatively with analgesia and physiotherapy:
however it is accepted that the post mortem indicated a rare Young-Burgess AP1 fracture.
Investigations should have been undertaken to explore the possibility of an underlying
traumatic injury.
2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been
undertaken on improving trauma care of the elderly with a focus on the emerging evidence-
based pathway of “silver trauma” care. This training programme, which included simulated
exercises, is currently suspended but will be resumed shortly.
2.3. The Trust is committed to implementing the “silver trauma” screening system in ED for frail
patients presenting with ‘low energy’ trauma with an assessment led by a senior clinician
(ST 4 +) if there are any red flag signs for escalation.
2.4. The facts and identified failures in this matter will be presented as a case study at a Multi-
disciplinary Grand Round session, as soon as they resume, for teaching purposes when
clinicians will be reminded that D-Dimers are not to be used in isolation but in conjunction
with the recognised screening tool.
2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major
Trauma Patients – Second Edition whereby trauma units use an effective screening triage
tool on elderly patients who self-present or arrive by ambulance and this prompts an
immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we
have already introduced a “front door” team of specialist nurses to assess elderly frail
patients upon arrival in ED to expedite their transfer to the ward or escalate for medical
advice or discharge as appropriate.
Trust Response to point 1.6 above
2.6. Since publication in July 2018 of the National Quality Board (NHSE) Learning from
Deaths Guidance, the Trust Board is committed to embedding a culture of learning and ensuring
effective implementation of all aspects of learning from death. The Trust Mortality Team has
initiated a system with the local Coroners Court to ensure all post mortem reports are now
disclosed promptly following any patient’s death in hospital. The Medical Examiner also now
reviews PM Reports, to ensure that any concerns are highlighted through the Trust’s Patient
Safety programme via a link with the Trust Learning from Deaths Team. All post mortems will
now be shared with the doctor making the referral to the Coroner and the responsible
Consultant.
Yours sincerely,
Dr
Chief Medical Officer
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