Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0333, written 6 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Oct 2021 |
|---|---|
| Reference | 2021-0333 |
| Deceased | Michael Jaggs |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| Organisation named | Homerton University Hospital NHS 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 Michael Anthony JAGGS (died 16.01.21) THIS REPORT IS BEING SENT TO: Chief Executive MedPure Healthcare Stockley Park 4 Long Walk Road Uxbridge UB11 1FE 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 28 January 2021, I commenced an investigation into the death of Michael Jaggs, aged 72 years. The investigation concluded at the end of the inquest on 21 September 2021. I made a determination at inquest as follows. Michael Jaggs was admitted to hospital on 15 January 2021 and treated for hyperkalaemia. He developed hypoglycaemia as a complication of this treatment. The agency nurse looking after him failed to escalate his deterioration to doctors, and he died from the hypoglycaemia. He was suffering from several chronic co-morbidities, but his death occurred when it did as a direct consequence of the failure to escalate his condition for medical attention. 4 CIRCUMSTANCES OF THE DEATH 1 Mr Jaggs was looked after by a nurse from your agency. By 3am on 16 January 2021, he had a blood sugar level of 1.9 and the agency nurse did notify the nurse in charge, who instructed her to bleep a doctor to prescribe dextrose. The agency nurse told me that either she did not hear that instruction or she did not act upon it. In any event, she did not bleep that doctor, or any of the others available. By 3.45pm, when the nurse in charge was able to leave her patient and take off the full personal protective equipment she had been wearing, she found from the agency nurse that Mr Jaggs’ blood sugar had dropped to 1.2 and he was unresponsive. 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. The agency nurse accepted in court that she should have sought prompt medical attention for Mr Jaggs and that she should have made a contemporaneous medical record of all his blood sugar readings. However, despite this sub optimal care, she said that she has not received any additional training from you following the incident. And she said that you did not ask her to draft a reflective statement, as the hospital trust had several times requested that you arrange. The trust has undertaken a great deal of work with its own staff to reduce the likelihood of such a failure in the future. I am extremely concerned that no similar learning is taking place within your agency. 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 6 December 2021. I, the coroner, may extend the period. 2 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. , Michael Jaggs’ daughter • • Homerton University Hospital NHS Trust • Care Quality Commission for England • HHJ Thomas Teague QC, the Chief Coroner of England & Wales I would have copied this report to the regulator of nurse agencies, but I have not received details of that organisation from Homerton University Hospital and my office has been unable to identify it. 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 06.10.21 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.
RESPONSE Regulation 28: Prevention of Future Deaths report Michael Anthony JAGGS (died 16.01.21) 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. The agency nurse accepted in court that she should have sought prompt medical attention for Mr Jaggs and that she should have made a contemporaneous medical record of all his blood sugar readings. However, despite this sub optimal care, she said that she has not received any additional training from you following the incident. And she said that you did not ask her to draft a reflective statement, as the hospital trust had several times requested that you arrange. The trust has undertaken a great deal of work with its own staff to reduce the likelihood of such a failure in the future. I am extremely concerned that no similar learning is taking place within your agency. TIMELINE OF EVENTS 19-Jan-21 Brief incident email received with a request for a factual statement of events on trust template. 19-Jan-21 Incident email confirmed SI but no specific concerns around nurse Complaint acknowledged to the trust. Email sent to agency nurse requesting a statement of events on trust template Statement of events sent to trust for review 02-Feb-21 09-Feb-21 We requested an update on complaints from trust 02-Mar-21 Agency complaints team chase trust for an update 16-Mar-21 Agency complaints team chase trust for an update 23-Mar-21 Agency complaints team chase trust for an update 13-Apr-21 Agency complaints team chase trust for an update Agency complaints team chase trust for an update 04-May- 21 04-May- 21 05-May- 21 Full incident report received from trust. A request for a reflective statement is made at this point Details of incident forwarded to agency clinical nurse for review 06-May- 21 26-May- 21 Clinical nurse calls nurse to discuss incident and reflective statement Clinical nurse calls nurse to discuss incident and reflective statement Nurse became unreachable after this time and we were made aware by the trust on the 28th September that an inquest took place. We did re-engage with nurse shortly after to confirm a meeting with the trust. We met with Deputy Chief Nurse, Deputy Director of People of Homerton University and nurse on the 21st October 2021. During the course of this meeting, it was decided the nurse should self refer to the NMC. CONCERNS AND REMEDIAL ACTION 1. Initial incident and statement request was to obtain a statement of events. Further information on this initial incident could have allowed us to act more accordingly. However; a. We have since outsourced our complaints to a 3rd party clinical complaints handling team. b. We have implemented a policy of obtaining a reflective statement at point of complaint being received to better identify any remedial action required. c. Our clinical complaints team are able to offer additional training where there is a need highlighted. This is provided to the nurse immediately. If face to face training is required, this is offered at the earliest opportunity. d. It was 98 days before we received a detailed version of events from the trust. We will look to escalate this much sooner should no response be forthcoming. Additional training requirements have since been highlighted to nurse by our clinical complaints team and we have assisted the nurse is self-referring to the NMC. We can confirm the NMC referral has taken place and we are supporting the NMC with their investigation. Director Monday 6th December 2021 Complaint Process Flow Chart
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