Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0105, written 9 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Apr 2021 |
|---|---|
| Reference | 2021-0105 |
| Deceased | Janet Willcock |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | City of Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Sussex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LLB. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: ‘| 1. ES - Chief Executive, University Hospitals Sussex NHS Foundation Trust 2. A&E Clinical Lead at Princess Royal Hospital and Day Surgery Unit (Twineham Ward) - University Hospitals Sussex NHS Foundation Trust 3. EE — Assistant Manager, Medico-Legal, University Hospitals Sussex NHS Foundation Trust 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton & Hove. 2 CORONER’S LEGAL POWERS | 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 234 November 2020 | commenced an investigation into the death of Janet WILLCOCK. The investigation concluded at the end of the inquest on 31% March 2021. The conclusion of the inquest was “RECOGNISED COMPLICATION (NAMELY STROKE) OF APPROPRIATE SURGERY FOR CRITICAL AORTIC STENOSIS.” 4 CIRCUMSTANCES OF THE DEATH Mrs Willcock was a lady of 61 years who was diagnosed with critical aortic stenosis and bicuspid valve following emergency admission to Royal Sussex County Hospital with chest pains on 28th October 2020. She was optimised for surgery which took place as soon as it could on 17th November 2020. She had some post- operative bleeding and this was dealt with in a return to theatre the next day. On the 19th November Mrs Willcock suffered a major stroke. This was identified and treated in accordance with stroke protocols but, sadly, she died on 21st November VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB On 12th August 2020 Mrs Willcock had an episode of syncope, fell and fractured her wrist. She was taken to A & E at Princess Royal Hospital. On 28th August 2020, the fracture was fixed. On neither occasion was there evidence that her chest was auscultated. If it had been | FIND from the evidence that her heart murmur would have been heard. This failing represented a missed opportunity to diagnose and treat her aortic stenosis earlier. However, | am satisfied that this did not change the outcome for Mrs Willcock. 2020. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: — On 12' August 20 Mrs Willcock presented at A&E, Princess Royal Hospital having fainted and fallen. (1) She had a head injury and a fractured wrist. There is no evidence that her chest was auscultated. (2) On the 28' August 2020 Mrs Willcock attended for day surgery (fixation of her wrist fracture). Again, there is no evidence that her chest was auscultated. (3) The evidence | heard informed me that if it had been a new heart murmur it would have been heard which, taken with the syncope, should have resulted in an immediate referral to Cardiology. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 30 June 2021. |, Veronica Hamilton-Deeley, the Senior 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. VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 8 COPIES and PUBLICATION Son — Son Son Secretary of State for Health, Department of Health HE Chief Executive, NHS England CCG Chief Executive, CQC, , Head of Quality and Nursing CCG | have also sent it to:- ONOTRWN> 1. EE - GP (for his information). 2. Ms Penelope Schofield, West Sussex Senior Coroner as Princess Royal Hospital is in her jurisdiction. Who may find it useful or of interest. | 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 Date: 9" April, 2021 | SIGNED BY: / Yam luc A\eed sa Senior Coroner Brighton and Hove
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.
University Hospitals Sussex NHS Foundation Trust University Hospitals Sussex NHS Foundation Trust Trust Headquarters Royal Sussex County Hospital Eastern Road Brighton BN2 5BE 28 April 2021 Miss Veronica Hamilton-Deeley HM Senior Coroner for Brighton & Hove The Coroner's Office Woodvale Lewes Road Brighton BN23QB Dear Miss Hamilton-Deeley The late Mrs Janet Willcock Following receipt of your Regulation 28 report of 9 April 2021, your concerns have been discussed at the Trust's Mortality Review meeting and by Trust Directors and Executives. Sadly, Mrs Willcock died of a stroke in November 2020, which was a recognised complication of necessary surgery - itself a consequence of her emergency admission in October 2020. Our thoughts are with Mrs Willcock's family. We acknowledge that there is no evidence in Mrs Willcock's clinical records of her heart being auscultated when she attended the hospital during August 2020. However, we agree with you that this did not change the outcome for Mrs Willcock, who died of a documented complication that could not have been influenced by any earlier intervention. We do not believe that there are issues with the Trust's systems or processes in relation to cardiac examination - and specifically auscultation. Clinical training and experience determine the examinations and investigations that are undertaken in all our patients; whether or not the heart is examined in a particular patient is always an individual clinical judgement, determined in real time by the specific clinical presentation. For example, we would not expect an Anaesthetic clinician working in a Day Surgery department to examine the cardiovascular system when carrying out a procedure under local anaesthetic. However, having personally reviewed Mrs Willcock's clinical records and in discussion with our Emergency Department Governance Lead, I have recommended that Mrs Willcock's case is presented at the next Governance Meeting, to ensure learning and to highlight the importance of auscultation in all patients presenting, like Mrs Willcock with unexplained syncope. Furthermore, if a clinical decision is taken not to auscultate, the rationale should be documented in the records. There will be an audit of the Emergency Department documentation to ensure standards are to the level expected. Once again, our thoughts are with Mrs Willcock's family and we would be happy to meet with them should they wish. Yours sincerely Dr Medical Director, University Hospitals Sussex NHS Foundation Trust
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