Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0050, written 17 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 | 17 Feb 2022 |
|---|---|
| Reference | 2022-0050 |
| Deceased | Chloe Lumb |
| Coroner | Karin Welsh |
| Coroner area | Teesside and Hartlepool |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
• Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Rt Hon Sajld Javid MP Secretary for State for Health and Social Care ........................................ .. Dept for Health and Social Care 39 Victoria Street ........................................ .. London SW1H OEU....................................... 1 CORONER I am Miss Karin Welsh Assistant Coroner for the area ofTeesside and Hartlepool 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On Fourteenth January 2021 I commenced an investigation into the death of Chloe May LUMB aged 24. The investigation concluded at the end of the inquest on 111n February 2022 and in Redcar on a1n January 2021. She was known established that Mrs Lumb died at to have a genetic risk of aortic dissection that was being monitored. She presented to James Cook University Hospital Middlesbrough (South Tees NHS Foundation Trust) on 4111 January 2021 when a diagnosis of aortic dissection should have been made because of her clinical symptoms and imagining that was carried out. When she contacted the hospital on 5111 January 2021 because of ongoing symptoms (having been discharged earlier that day) she should have been asked to return. A diagnosis of aortic dissection and appropriate treatment would have prevented her death. The cause of death was I a Acute Hemopericardium due to I b Ruptured Ascending Aortic Dissection due to I c Cystic Medial Necrosis My conclusion was that Mrs Lumb died as a result of an undiagnosed and therefore untreated aortic dissection 4 CIRCUMSTANCES OF THE DEATH , Redcar on 8th January 2021. She was known to Chloe May Lumb died a have a genetic risk of aortic dissection. She presented 'at hospital on 4th January 2021 when a diagnosis ofaortic dissection should have been made and she should have been asked to return to the hospital on the 5th January 2021. A diagnosis of aortic dissection and appropriate surgical treatment would have prevented death. 5 CORONER'S CONCERNS j The MATTERS OF CONCERNS ate as follows: There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition. When the Emergency Department were contacted by Ms Lumb on 5th January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP The trust identified these shortcomings prior to the Inquest and have produced a guidance or pathway document for use in the Emergency Department for suspected aortic dissection called 'Management of Adult Patients with Suspected or Proven Acute Aortic Syndromes including Aortic Dissection'. Additionally they produced a Standard Operating Policy to ensure that those patients identified with genetic conditions predisposing to acute aortic syndromes have an Emergency Heath Care Plan and a CPI flag Copies of both documents are attached 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent Mure deaths and I believe you (and/or your organisation) have the power to take such action. All Trusts within England should be made aware of the circumstances of this case and particularly the necessity to have in place a similar guidance or pathway document and standard operating policy to be achieved via the nhs patient safety framework 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 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 Family South Tees NHS Foundation Trust 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 '\~u~ Karin Welsh HM Assistant Coroner for Teesslde and HartleDool
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