Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0149, written 10 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 | 10 May 2021 |
|---|---|
| Reference | 2021-0149 |
| Deceased | John Lott |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | City of Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Fax: Brighton (01273) 292047 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, m Chief Executive Officer, Nuffield Health, London 2. Matron, Nuffield Hospital, Woodingdean, Brighton 3. Dr. Consultant orthopaedic surgeon 1 CORONER 1am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and 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 10'" November 2020, | commenced an investigation into the death of Mr. John Charles LOTT The investigation concluded at the end of the inquest on 29" April, 2021.The conclusion of the inquest was a Narrative Conclusion:- “JOHN LOTT DIED FOLLOWING ELECTIVE SURGERY FOR A DEFUNCTIONING ILEOSTOMY. POST-OPERATIVELY THERE WERE TWO MISSED OPPORTUNITIES TO TRANSFER HIM FROM THE PRIVATE HOSPITAL TO AN ADJACENT HOSPITAL WITH LEVEL 2 AND 3 INTENSIVE CARE FACILITIES. HAD HE BEEN TRANSFERRED WHEN HE SHOULD HAVE BEEN IT IS POSSIBLE THAT THE OUTCOME FOR HIM WOULD HAVE BEEN DIFFERENT.” 4 CIRCUMSTANCES OF THE DEATH John Lott was a 78 year old man who had a procedure to forma defunctioning ileostomy on 21.10.20. Post-operatively there were two occasions (on the 27th and the 29th) when he was sufficiently unwell to require transfer from the 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 Fax: Brighton (01273) 292047 private hospital where he was, to the acute NHS hospital which had the intensive care facilities which | FIND that he needed. He was not transferred on either occasion. He deteriorated rapidly and around the time of transfer, on a background of inadequately treated hypoglycaemia, he suffered myocardial ischaemia and infarction. He did not have the reserves to recover from this and died on 8th November 2020. See Record of inquest 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: — (1) On 27" October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29" October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred. (3) When ae: Consultant “in charge” of Mr. Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support. Why not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers? 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 29" July 2021. |, 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. VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Fax: Brighton (01273) 292047 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons ee | i) = Chief Executive, NHS England + Chief Executive CQC NOORON = Trust Who may find it useful or of interest. Coroner. Head of Quality and Nursing Clinical Commissioning Group Secretary of State for Health, Department of Health ES — Medico Legal Manager- University Hospitals Sussex NHS | 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 9 Date: 10 May 2021 SIGNED BY: donc fevcaly Senior Coroner Brighton and Hove
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