Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0146, written 7 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 May 2021 |
|---|---|
| Reference | 2021-0146 |
| Deceased | Macaulay Wilson |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Community health care · 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: Prevention of Future Deaths report
Macaulay WILSON (died 26.09.20)
THIS REPORT IS BEING SENT TO:
1. Dr
and Dr
Senior Partners
Lower Clapton Group Practice
36 Lower Clapton Road
London E5 0PQ
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 8 October 2020 I commenced an investigation into the death of
Macaulay Wilson, aged 87 years. The investigation concluded at the end
of the inquest earlier today.
I recorded a medical cause of death of:
1a urosepsis
1b long term indwelling catheter not changed since October 2019
2 Alzheimer’s dementia, cerebrovascular accident,
chronic kidney disease, bladder cancer and prostate cancer
I made a determination at inquest that Mr Wilson died because a failure
to change his indwelling catheter for almost a year caused urosepsis.
The catheter should have been changed every 12 weeks.
1
4
CIRCUMSTANCES OF THE DEATH
Mr Wilson had an indwelling urinary catheter fitted to assist in the
management of his bladder cancer.
The Homerton University Hospital urology department failed to risk
assess his catheter change requirement and so did not recognise that
this was too complex medically for district nurses in the community and
should be dealt with by the department.
Then it cancelled an appointment (because of the COVID19 pandemic)
made for 27 April 2020 following a GP referral, and failed to make a plan
to bring Mr Wilson back.
And finally, his general practitioner having referred him a second time on
31 July 2020, the HUH urology department failed to make another
appointment.
Meanwhile, the Homerton University Hospital district nurses visited Mr
Wilson every week for catheter care, but never enquired as to whether
there had been any catheter change.
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.
(I should say that I heard at inquest that Homerton University Hospital
has formulated an action plan to minimise the risk of recurrence.)
The MATTERS OF CONCERN are as follows.
The Homerton University Hospital urology clinical nurse specialist wrote
to your practice on 18 February 2019, and included within the letter a
request that you arrange for district nurses to change Mr Wilson’s
indwelling catheter in 12 weeks.
A doctor from your practice did consider the letter, did action it and did
write to the district nurses, but did not include a specific request for
catheter change (as opposed to catheter care, which does not include
change of the catheter).
It seems that your doctors’ use of language in this situation would benefit
from further consideration.
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 5 July 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 following.
Dr
HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, medical director, Homerton Hospital
, son of Macaulay Wilson
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
DATE SIGNED BY SENIOR CORONER
07.05.21 ME Hassell
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.
; In response to HM Senior Coroner for Inner North London's Regulation 28 Prevention of Future Death (PFD) Report of 7 May 2021 concerning Mr Macaulay Wilson Following the inquest touching on the death of Mr Wilson, HM Senior Coroner for Inner North London, Mary Hassell, concluded that Mr Wilson’s death was as a result of urosepsis secondary toa failure to change his indwelling catheter for almost a year, when it should have been changed every 12 weeks. The medical cause of death was confirmed as 1a urosepsis and 1b long term indwelling catheter not changed since October 2019. Concerns were raised within a Regulation 28 PFD report to Lower Clapton Group Practice on the manner and accuracy with which important information - passed from the specialist team to the GP practice - was then communicated to the district nursing team responsible for the delivery of the proposed treatment plan in relation to Mr Wilson’s indwelling catheter. The Coroner noted in particular a loss of detail at the point when a practice GP conveyed the specialist team’s instructions of 18 February 2019, such that the words catheter ‘care’ replaced the words catheter ‘change’. On behalf of Lower Clapton Group Practice, the practice partners Dr Mand Or ould like to express their deepest condolences to the family and friends of Mr Wilson. The practice notes the seriousness of these events and in response has undertaken the following activities to prevent a recurrence. Lower Clapton Group Practice has introduced a system to ensure that when the practice receives correspondence containing instructions directed towards other members of the wider clinical team involved in a patient’s care, such as district nursing, the relevant instructions will be clearly highlighted and a copy of the original letter will accompany any onward referral to ensure there is no loss of information or message clarity. We are undertaking an audit of all patients who have catheter products on their prescriptions. We will ensure that we clearly record in their notes how frequently their catheter should be changed and which service is responsible for doing this. We have written an electronic template within our clinical system to aid us in capturing the above data. This will be completed for all patients with a new indwelling catheter to ensure we have accurate information in connection with catheter care, catheter change frequency and the identity of the responsible team. We have written an electronic alert which activates when a patient is identified as being in receipt of catheter products (from their prescription page). This will prompt users to check for when a patient's catheter was last changed and identify which part of the service holds responsibility for this. We have communicated the above to all members of the team including the person responsible for coding incoming patient related correspondence and these processes have been incorporated into our induction program. We have informed our local medicines management team about this case to ensure they can disseminate this risk within their monthly newsletter so that other practices can ensure a similar event does not occur. We have reported the incident via the National Reporting and Learning System and have informed the CCG. We are amending the City and Hackney wide EMIS template which is used when visiting housebound and vulnerable patients to include parameters such as catheters and catheter change as well as other issues which may increase patient risk such as pressure sores and falls. A report has also been be passed to the CAC, expanding on these activities. Lower Clapton Group Practice is grateful for the opportunity the Regulation 28 report has provided to review and strengthen our processes. We hope these activities will not only reassure HM Senior Coroner of our commitment to delivering safe care but also Mr Wilson's family and the wider community we serve. a GP Principle Date a aS Sr Zoe! . oo GP Principle vate QUT TAs WO.
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