Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0040, written 12 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 | 12 Feb 2021 |
|---|---|
| Reference | 2021-0040 |
| Deceased | Gillian McKinlay |
| Coroner | Dr James Adeley |
| Coroner area | Lancashire & Blackburn with Darwen |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | East Lancashire Hospitals 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.
for Lancashire & Blackburn with Darwen
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
East Lancashire Hospitals NHS Trust Medical Director and Legal Services Department
Care Quality Commission
Gillian McKinlay's family
1
CORONER
2
3
4
I am Dr James Adeley Senior Coroner for Lancashire & Blackburn with Darwen
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
INVESTIGATION and INQUEST
CIRCUMSTANCES OF THE DEATH
Mrs Gillian McKinlay, 68 years of age, was admitted to the Accident & Emergency Department of
Royal Blackburn Hospital on 23 April 2018. The provisional diagnosis was of small bowel
obstruction and both the A & E and Surgical Registrars requested siting of a nasogastric tube to
decompress the bowel. The NG tube was not sited prior to Mrs McKinley's death four hours later,
which in the Coroner's view, contributed to the death. Despite Early Warning Score indications
that there should have been a significant review of Mrs McKinlay's condition in the 2 ½ hours
before she arrested, there is no evidence that any such review took place.
A copy of the summing up is attached to this document for further information.
CORONER’S CONCERNS
5
The MATTERS OF CONCERN are as follows:
1. For patients remaining for a considerable period of time in the Accident and Emergency
Department there is no clear indication or understanding as to who is responsible for the
overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no
evidence in the medical records that any such review took place by A & E medical staff
or that the matter was referred to any of the other clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to
the EWS scores had occurred, there is no evidence of escalation by the nursing staff
either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the
following concerns concerning the adequacy of the Trust's investigation and measures
taken:
a. NG tube not sited - the Trust's response does not address why there was a
failure of escalation or referral back to the requesting teams and the updated
action plan that "training on insertion should shorten time taken to decompress"
is inadequate;
that the EWS score mandated review by the acute care team (whoever that may
b.
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
c.
be for these purposes-see first point), there is no evidence in the medical
records apart from a blood gas that any such review took place or that any
treatment occurred;
the investigating consultant had informal conversations during the investigation
with a middle grade doctor who had performed the arterial blood gas but was
unable to state who this was, why no medical records were created and why no
action was taken
the report states that there was a "correct escalation of the EWS at every stage"
for which no evidence has been provided and appears to be factually incorrect
e. medical records created by the surgical registrar were in accurate as they were
d.
f.
completed by a junior doctor and not checked
that no audit has taken place to ascertain whether the Trust's measures have
had the appropriate effect.
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 before Friday, 28 May 2021. The period for your
response has been extended due to the Covid 19 pandemic.
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,
namely East Lancashire Hospitals NHS Trust Medical Director and Legal Services Department
and Gillian McKinlay's family
I have also sent it to the Care Quality Commission
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
Dated
Signature
for Lancashire & Blackburn with Darwen
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
Tel 01772 536536 | Fax 01772 530752
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