Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0254, written 12 Jul 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 Jul 2021 |
|---|---|
| Reference | 2021-0254 |
| Deceased | Stephen Walker |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Free London NHS Foundation Trust |
| 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
Stephen Francis WALKER (died 06.04.21)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
Royal Free Hospital
Pond Street
London NW3 2QG
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 21 April 2021, I commenced an investigation into the death of
Stephen Walker, aged 79 years. The investigation concluded at the end
of the inquest earlier today.
Dr Walker’s medical cause of death was:
1a aspiration pneumonia and acute pulmonary oedema
1b small bowel ileus and ischaemic small bowel
1c ileostomy reversal
2 aortic incompetence
I made a determination at inquest that Stephen Walker died from the
complications of medical treatment, being an ileus following an ileostomy
reversal. Earlier placement of a nasogastric tube would have improved
his chance of survival, because it would have reduced the risk of vomiting
and so of aspiration.
1
4
CIRCUMSTANCES OF THE DEATH
Dr Walker was admitted to the Royal Free Hospital for an ileostomy
reversal on 1 April 2021. He began vomiting on the morning of 5 April
and felt extremely unwell, but a nasogastric tube was not placed until that
evening, at which point 2 litres was aspirated. He was then admitted to
the intensive care unit, but died the following day.
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. Dr Walker’s condition had deteriorated by the time of the morning
ward round on Easter Monday, 5 April 2021. He said that he felt
awful and had begun vomiting. Dr Walker wondered if this was
secondary to opiate analgesia, and this was recorded as the
clinical impression.
However, no record was put before me at inquest indicating that
the clinical fellow undertaking the ward round conducted an
abdominal examination, no subsequent early medical review was
fixed and no nasogastric tube was passed.
2. At the morbidity and mortality meeting on 24 June, the registrar
said that Dr Walker was offered a nasogastric tube but declined.
However, I was told at inquest that there was no record of this.
3. I was told at inquest that, at lunch time on 5 April, nurses twice
bleeped for a medical review, but there was no record that a
medical review was undertaken, or that this was chased.
4. At inquest, I asked the colorectal surgeon with care of Dr Walker
to check matters in the online medical records before him.
However, he said that he was in difficulty because they were so
confusing in the way that they were laid out and completed.
If the records are so confusing that a consultant cannot read them
easily, then that is obviously sub optimal in terms of care.
I am aware that the chair of the panel that has already considered the
circumstances in which Dr Walker died, the consultant surgeon
, intends to conduct a more in depth review of the medical records.
2
I write this report partly in the hope that my concerns will feed into
review. As such, I should be grateful if a copy of my PFD report
could be forwarded to him before he completes any such review.
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 13 September 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.
•
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, wife of Stephen Walker
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
12.07.21 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.
Chief Executive Office 2nd Floor, Executive Suite Royal Free London NHS Foundation Trust Royal Free Hospital Pond Street, London, NW3 2QG P.!Z:k1 Royal Free London NHS Foundation Trust Private and Confidential Coroner ME Hassell Senior Coroner St. Pancras Coroner's Court Carnley Street London N1C 4PP Date: 14 October 2021 Dear Coroner Hassell Re: Prevention of Future Deaths Report following inquest into the death of Stephen Walker (Date of death: 06/04/2021) I am writing to you following my letter of 26 August 2021, in response to the matters of concern raised in your Regulation 28 Report: Prevention of Future Deaths, following the Inquest in to the death of Dr Stephen Walker. In my letter of 26 August 2021, we confirmed that this case was presented to our Safety Incident Review Panel, and it was agreed to declare it as an externally reportable serious. incident yvith our commissioners. The investigation has now concluded and the report has. been submitted to our commissioners. I attach a copy of the completed investigation for you, in Appendix 1 , including the action plan and identified learning. The investigation was led by a senior clinician, not associated with the service, or Dr Walker's care and treatment, and the investigating panel comprised a multidisciplinary team who were also not involved in the incident, and included staff experienced in root cause analysis investigation, human factor analysis and effective solution development. · We appreciate having the opportunity to review Dr Walker's care and treatment, which has allowed us to identify a number of learning points for our organisation around documentation, escalation, incident reporting and recording outcomes of Mortality and Morbidity meetings. I would like to inform you that the Royal Free Hospital has recently launched a new electronic patient information system called EPR, which allows our clinical teams to have access to contemporaneous clinical records. We are confident that this will support improvements in both documentation and communication. Doctors working in the service have also been asked to ensure that they always escalate the refusal of an NG tube to the Consultant on call . 1 In addition, we are currently reviewing our processes for recording outcomes of Mortality and Morbidity meetings, by actively exploring existing systems within the organisation. In addition to commissioning the serious incident investigation, a learning from death review was also commissioned, and approved at our hospital Mortality Review Group on 8 October 2021, which we also include, in Appendix 2, for your information. Following finalisation of the investigation, Dr Walker's.wife will now be offered a copy of the final investigation report and will also be invited to attend a meeting with representatives of the Trust, to discuss the investigation findings and any learning for the Trust. The final report, including the shared learning will also be shared with all staff involved in the incident, to facilitate learning and reflective practice. The learning from the incident will also be shared widely at the Service Line meeting, the Divisional Quality & Safety Board meeting, the Clinical Performance and Patient Safety meeting, as well as other relevant forums and newsletters. I would again like to reassure you that we take any untoward death of a patient extremely seriously and would like to thank you for providing me with the opportunity to respond to this Regulation 28 F3,eport. Please let us know if you require any further information at this point. Yours sincerely Dr Chief Executive Royal Free Ho~pital 2
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