Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0060, written 3 Mar 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 Mar 2021 |
|---|---|
| Reference | 2021-0060 |
| Deceased | Helen McLean |
| Coroner | Andre Rebello |
| Coroner area | Liverpool and Wirral |
| Category | 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive St Helens and Knowsley Hospitals NHS Trust Whiston Hospital Warrington Road Prescott L35 5DR 1 CORONER I am Andre REBELLO, Senior Coroner for the area of Liverpool and Wirral 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. 3 INVESTIGATION and INQUEST On 25/11/2020 I commenced an investigation into the death of Helen Margaret Mclean aged 90. The investigation concluded at the end of the inquest on 03 March 2021. The conclusion of the inquest was an Accidental death with the cause of death being: I a Stroke (Ischaemic) 4 CIRCUMSTANCES OF THE DEATH On the 11th August 2020 Helen Margaret McLean was admitted to Whiston Hospital. During the admission her warfarin medication was changed to 60mg Edoxaban. Following discharge on 24th September 2020 no discharge summary was received by her GP. She changed from Pilch Lane GP Practice to Aintree Park Group Practice on 28th September 2020. Aintree Park Group Practice eventually received a copy of the discharge letter from Whiston Hospital on the 8th October 2020, having chased the same. On the 26th October 2020 Mrs McLean transferred home to Christopher Grange Nursing Home. She also transferred back to Pilch Lane GP Practice. There is a no record of Pilch Lane Practice ever receiving the discharge letter from Whiston on interrogation of digital systems. On the 28th October 2020 Christopher Grange reordered all medication, including Edoxaban from Mrs McLean's prescription which came with her when she was admitted. Pilch Lane prescribed all medication apart from Edoxaban. remains unclear how or why this was done. It Christopher Grange did not cross-reference medication prescribed with medication requested. Christopher Grange stopped the previous medication administration chart and used a new chart which came with the new dispensed prescription. 8 Edoxaban tablets remaining were discarded and Mrs McLean was without medication to prevent blood clots causing circulatory problems from the 5th November 2020. On the 18th November 2020 Mrs McLean was admitted to hospital after an ischaemic stroke. She died on the 21st November 2020. Edoxaban may have prevented this fatal event. It is found more likely than not that 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) Following admission to Whiston Hospital on 12th August 2020 the patient was discharged home and a discharge summary was issued. Her GP Practice did not receive this. It is unclear as to why the original summary including medications was not received. However, though summary names a GP but failed to include the GP Practice name and the GP practice identifier was wrong. (copy included only for the recipient’s reference). Given the patient’s NHS number was accurately stated, please explain this error and rectify your system to prevent repetition. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 28 April 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 all Interested Persons 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 Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 03 March 2021
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.
NHS St Helens and Knowsley Teaching Hospitals NHS Trust Whiston Hospital Warrington Road Prescot Merseyside L35 5DR 28 April 2021 André Rebello OBE Senior Coroner Liverpool and Wirral Area HM Coroner's Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD Dear Mr Rebello Regulation 28 report issued at the inquest into the death of Helen Margaret McLean | write in relation to the above inquest, following which you issued a Regulation 28 report on 03 March 2021. Thank you for bringing the concerns identified to our attention. | would like to take this opportunity to provide assurance to both you and Helen McLean’s family that the Trust takes the concerns raised very seriously and actions have been taken to address these as detailed below. | would like to offer my sincere condolences to Mrs McLean’s family for their loss. The Trust has investigated the concerns raised, including a detailed analysis of the IT systems and in-depth discussions with the Trust's clinical staff, IT specialists and the IT suppliers. The investigation identified the following issues. There were two separate but connected IT systems involved: e Careflow Electronic Patient Record (EPR), which is the main system used by our clinical teams, for example, to record clinical interactions with patients, order tests and review the results of clinical investigations e Integrated Care Environment (ICE), which is used to create the discharge summaries. Patient demographic details, inclusive of GP practice name and address are fed from the NHS national spine database via Careflow EPR into the ICE system It was possible to create discharge summaries from both systems. Our extensive investigation identified that there were specific instances when the way in which the two systems interacted resulted in a failure to attach the full GP address. This prevented the transfer of the letter electronically to the GP, even though the correct GP address was in EPR. A technical solution has been implemented to remove this error, which will prevent this happening again. We have completed comprehensive checks that have confirmed that all new discharge summaries contain the relevant GP details. UNIVERSITY OF Liverpool 7 A University Clinical Education Centre John Moores LIVERP OOL SIMIC} University We have checked all other patients and have issued a copy of the discharge summary to the GP for anyone affected. In addition, we have made the relevant IT suppliers aware of these findings in order that they can take the appropriate actions. | trust that this response provides assurance that lessons have been learned and improvements implemented. Please do not hesitate to contact me if you require any further information. Yours sincerely Chief Executive UNIVERSITY OF U dl Ed Liverpool niversity Clinical Education Centre John Moores LIVERPOOL 7 WAALS} University
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