Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0084, written 16 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Mar 2022 |
|---|---|
| Reference | 2022-0084 |
| Deceased | Billy Longshaw |
| Coroner | Chris Morris |
| Coroner area | Greater Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Great Western Hospitals NHS Foundation Trust |
| 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1)
Foundation Trust.
2)
Medical Council.
1 CORONER
, Chief Executive, Great Western Hospitals NHS
, Chief Executive and Registrar, The General
I am Chris Morris, Area Coroner for Manchester South.
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://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 5th May 2021, Alison Mutch OBE, Senior Coroner for Greater
Manchester (South) opened an inquest into the death of Billy Longshaw
who died on 7th March 2021 at Stepping Hill Hospital, Stockport aged 22
years.
The investigation concluded with an inquest which I heard on 21st
February 2022.
The inquest concluded with a Narrative Conclusion to the effect that Mr
Longshaw died as a consequence of complications of an undiagnosed
sigmoid volvulus.
1
4 CIRCUMSTANCES OF THE DEATH
Billy Longshaw died at Stepping Hill Hospital, Stockport on 7th March
2021. Mr Longshaw had a complex medical history, including significant
learning disabilities.
A post-mortem examination undertaken by Dr
Histopathologist, determined that the medical cause of Mr Longshaw’s
death was:
, Consultant
1) a) Acute bowel obstruction;
b) Ischaemic sigmoid volvulus.
2) Cardiomyopathy due to D2-Hydroxyglutaric aciduria.
Mr Longshaw had been taken to the Emergency Department of Great
Western Hospital, Swindon, following experiencing sudden onset
abdominal pain and an episode of vomiting on a car journey.
In the Department, Mr Longshaw was found to have mostly normal
physiological observations, and his abdominal examination was
considered to be normal by the junior hospital doctor who saw him.
Mr Longshaw was permitted to leave the Department without basic blood
tests being taken, any diagnosis being made, or serious abdominal
pathology being fully excluded.
On the balance of probabilities, the sigmoid volvulus which led to Mr
Longshaw’s death was present (albeit at an early stage) when he was
assessed in Swindon.
2
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows. –
To the Chief Executive, Great Western Hospitals NHS Foundation Trust
1) Notwithstanding Mr Longshaw died within 24 hours of being seen
in the Emergency Department at Great Western Hospitals,
Swindon, in circumstances where he was permitted to leave
without basic blood tests being taken, any diagnosis being made,
or serious abdominal pathology being fully excluded, it is a matter
of concern that the Trust has not undertaken a detailed
investigation into the care and treatment provided to him.
Prompt, rigorous and effective investigations into serious clinical
incidents are essential to deriving learning and improving patient
safety;
2) The ’48 Hour Report for Significant incidents resulting in Moderate
Harm and above’ prepared by an ED Consultant and others is
fundamentally and obviously flawed (even when read against the
Trust’s own medical records), prefaced as it is by the assumption
that ‘the patient self-discharged against medical advice’. The
Trust’s (limited) review of this matter represents a missed
opportunity to consider vital issues such as the presentation of
patients with significant learning disabilities to the Emergency
Department, and the practical application of the Mental Capacity
Act 2005 in this clinical setting.
To the Chief Executive and Registrar, The General Medical Council
3) Mr Longshaw’s death raises issues as to the adequacy of
education provided to medical students as to the Mental Capacity
Act 2005, and doctors’ of all levels familiarity with the practical
application of this legislation in clinical settings, and accompanying
guidance such as that produced by the General Medical Council in
this regard.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
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 11th May 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
3
why no action is proposed
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to Mr
Longshaw’s parents.
, Medical Director of
I have sent a copy of my report to Dr
Bath, North East Somerset, Swindon and Wiltshire CCG and to the Care
Quality Commission who may find it useful or of interest.
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:
16th March 2022
Signature:
Chris Morris HM Area Coroner, Greater Manchester (South).
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