Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0041, written 10 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2022 |
|---|---|
| Reference | 2022-0041 |
| Deceased | John Skinner |
| Coroner | Graham Danbury |
| Coroner area | Hertfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
CORONER'S OFFICE AREA OF HERTFORDSHIRE Date: 10 February 2022 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive of NHS England 1. CORONER I am Graham Danbury Assistant Coroner for Hertofdshlre 2. CORONER'S LEGAL POWERS I 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. http:/lwww,legislation.goy.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.leqislation.gov .uk/uksV2013/1629/part/7/made 3. INVESTIGATION AND INQUEST On 18 May 2020 I commenced an Investigation Into the death of John Paul SKINNER. The Investigation concluded at the end of the Inquest on 4 November 2021. The conclusion of the Inquest was Mr Skinner was admitted to Watford General Hospttal suffering tonic clonlc seaures. The doctors caring for him decided to administer Phenytoln, an anti-epileptic medication. The Junior doctor Instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure In verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered. 1 a Acute Csrdlac Failure 1 b Phenytoln Toxicity 1c II Chronic lachaemlc Heart Disease, Urolithlasis 4. CIRCUMSTANCES OF DEATH . On the 15th May 2020 John Skinner was admitted to Watford Hoapltal suffartng from a tonic clonlc seizure he had a background of cannabis usage and a subdural empyema In 201 Othat had left him with epilepsy. On arrival at hospital he again had another tonic clonlc seizure and focal seizures. He was given 3600 mg of phenytoln. He arrested within 16 minutes and died and could not be revived. 5. CORONERS CONCERNS During the course of the inquest the evidence revealed matters giving rise to concem. 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) The Junior doctor Instructed to administer phenytoln did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15kmg/kg was heard by the Junior doctor as 50mg/kg resulting in administration of a significant overdose. This Is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you NHS England 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 12th April 2022. 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 Chief Coroner and to the following Interested Persons partner of John Skinner. I 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. Dated 10 February 2022 s~~ L✓ Assistant Coroner for Hertfordshire
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