Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0025, written 3 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 | 3 Feb 2021 |
|---|---|
| Reference | 2021-0025 |
| Deceased | Christopher Smith |
| 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 | none published |
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 of Medway NHS Foundation Trust
2. Head of Adult Safeguarding Kent County Council
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.
[HYPERLINKS]
3
INVESTIGATION and INQUEST
On 10 April 2019 an investigation was commenced into the death of CHRISTOPHER
SMITH, 63. The investigation concluded at the end of the inquest on 31 July 2020.
The conclusion of the inquest was a narrative conclusion.
‘Christopher Smith died at Medway Maritime Hospital on 4th March 2019 of
pneumonia with abscesses due to cellulitis with ulceration caused by peripheral
vascular disease. He had two admissions to hospital in January and February and
treated for sepsis and hyponatremia. He was discharged home alone on 10th
February with intractable leg ulcers with no home assessment and no district nurse
referral. This, and a lack of adequate nourishment caused an exacerbation of his leg
ulcers that probably accelerated his death.’
4
CIRCUMSTANCES OF THE DEATH
Christopher Smith was admitted into hospital on 21st January 2019 with a history of
peripheral vascular disease, extensive leg ulcers and epilepsy and was diagnosed with
cellulitis and later with a chest infection. He was found not to have capacity for his treatment
and a deprivation of liberty authorisation was sought.
He remained on a discharge ward from 2nd February until 10th February during which time
he suffered deterioration, nursing documentation was that he remained confused and his
capacity for decisions around his care and treatment was not reassessed. Mr Smith was
discharged without appropriate discharge planning or district nurse referral and his leg
ulcers were not treated or dressed. Transport staff had significant concerns that his home
was not safe or fit for habitation and raised a safeguarding alert when the hospital stated
there was no bed for him. His family were not informed and found him five days later on the
floor unable to move and with no dressings on his legs.
He was readmitted to hospital on 15th February with sepsis, confusion and self-neglect and
received treatment. There was a delay seeking the advice of a dietician and the advice was
not followed. Mr Smith’s assessed nutritional needs were not met. He continued to
deteriorate and died on 4th March 2019.
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. –
Evidence was heard that:
(1) A recommended home assessment was not completed as part of Mr Smith’s planned
discharge from hospital.
(2) The next of kin was incorrectly recorded on Mr Smith’s medical records and the family
were not informed of his discharge home as part of the discharge planning that he
required care.
(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th
February even though he suffered a deterioration in his medical condition. Mr Smith’s
capacity fluctuated during his admission, he was noted by nurses to be confused and
his capacity was not reassessed.
(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led
to assumptions being made that Mr Smith
a. had capacity to make decisions about his care and treatment
b. was being cared for in the community.
(5) Mr Smith has extensive leg ulcers that required specialist input. No district nurse
referral was made to ensure that Mr Smith’s leg ulcers were treated.
(6) Transport staff returning Mr Smith home found he had no key. One was located and
on entering the property found conditions that caused them serious concern about the
hygiene and health and safety within the property with a leak, uncleanliness and
exposed electrical wiring and that there was no bed.
(7) Transport staff were informed by the hospital not to return Mr Smith to the hospital as
there was no bed available and they therefore raised a safeguarding alert. The
safeguarding alert was not acted upon and Mr Smith was found by family after five
days lying on the floor of his home with no dressing on his legs, unable to move and
with no access to food or drink.
(8) On readmission to hospital his dietary requirements were not adequate for his needs.
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 31st 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
(brother) and
(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 it
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 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.
9
3rd February 2021
Signature:
Assistant Coroner Mid Kent & Medway
3
See every Prevention of Future Deaths report matching Medway NHS Foundation 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.