Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0127, written 28 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Apr 2022 |
|---|---|
| Reference | 2022-0127 |
| Deceased | Vilem Bock |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater 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 3 INVESTIGATION and INQUEST On 10th June 2021 I commenced an investigation into the death of Vilem Bock. The investigation concluded on the 14th February 2022 and the conclusion was one of Narrative: Died from the consequences of anticoagulation given for a week when there was a delay in a CTPA being performed due to arrangements to overcome a language barrier not being made at the time the CTPA was arranged. The medical cause of death was 1a Multiorgan failure ;1b Sepsis; 1c Infected retroperitoneal haematoma following anticoagulation therapy on background of community acquired pneumonia with thrombocytopenia 4 CIRCUMSTANCES OF THE DEATH Vilem Bock had very limited English and needed family support or an interpreter/interpretation service to communicate effectively and to give consent for treatment. He was admitted to Tameside General Hospital and treated for sepsis. On 18th May 2021 it was suspected he had a pulmonary embolism (PE). He was commenced on anticoagulation medication. An inpatient CTPA was arranged for the next day. On 19th May 2021 the CTPA did not take place because no arrangements had been made for an interpreter to be present and the interpretation tool was not utilised. The radiology team decided that necessary checklist could not safely be completed due to this. The scan did not then take place until 25th May 2021. No PE was found when the CTPA was undertaken, and anticoagulation was stopped immediately. On 25th May he had abdominal discomfort and an urgent CT scan on 26th May confirmed a large retroperitoneal haematoma caused by the anticoagulation medication he had been on whilst awaiting the CTPA. He deteriorated as a consequence of the haematoma. He developed new symptoms of sepsis and on 2nd June an infected para-rectal haematoma was identified as the cause of the sepsis. On 4th June he was operated on to try to clear the infection and formation of defunctioning colostomy. He continued to deteriorate post operatively and died at Tameside General Hospital on 6th June 2021. 1 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. The Trust in question has taken steps since the death of Mr Bock to improve the identification of the need for an interpreter to prevent language being a barrier to access to treatment. However, it was unclear from the evidence given that from a national perspective there were protocols in place to ensure that other Trusts would avoid a similar situation arising where language was a barrier to accessing care 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 23/06/2022. 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 namely, General Hospital who may find it useful or of interest. (NOK) and Tameside 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 Alison Mutch HM Senior Coroner HM Coroner’s Court Manchester South 2
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.
To: Ms Alison Mutch Manchester South Coroner’s Court, 1 Mount Tabor Street, Stockport, SK1 3AG NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 8 September 2022 Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Vilem Bock who died on 6 June 2021 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28 April 2022 concerning the death of Vilem Bock on 6 June 2021. I would like to express my deep condolences to Vilem’s family. I note the inquest concluded that Vilem Bock died from the consequences of anticoagulation, given for one week between 18 and 25 May 2021, when there was a delay in a CT pulmonary angiogram (CTPA) scan being performed due to arrangements for an interpreter not being made at the time the CTPA was arranged. Following the inquest, you raised concerns in your Report regarding whether, from a national perspective, there were protocols in place to ensure that other Trusts would avoid a similar situation arising where language was a barrier to accessing care. Nationally, there is a protocol for Trusts to access translation services: Interpretation and Translation Services - NHS SBS. The Interpretation and Translation Services Framework Agreement provides a variety of translation and interpretation services. The services on this framework agreement include face to face (spoken language), British sign language (BSL), telephone interpretation and translation, document translation, plus video translation and interpretation. NHS staff are able to contact the service to secure interpretation services. The Tameside and Glossop Integrated Care Foundation Trust (TGICFT) have also shared the following information with the Clinical Commissioning Group that commissions the services: The following actions have been taken by TGICFT in relation to the provision of interpreters and translation services, and in disseminating the learning across the relevant teams in relation to the inquest: • The TGICFT interpretation and translation policy was reviewed in regard to the systems and processes used for booking interpreters, to ascertain if this was a potentially contributory factor. • Currently the Trust has a contract with DA Languages to provide interpretation and translation services. This includes the provision of face to face interpreting, telephone interpreting and the use of video interpreting. As part of the contract, ongoing conversations are taking place to see how additional mobile applications can be used to access interpreters in unplanned situations. • A 7-minute briefing of the learning from local investigations and the inquest was completed, and this has been shared with the relevant staff. The importance of documentation reiterated through the sharing of this briefing was also directly discussed with staff, and this was led by a senior clinical lead. • The investigation outcome will be shared as part of the Clinical Support Services Quality and Safety Meeting for awareness and learning, to help identify any similar instances or themes that need responding to. • Reflective discussions have been held with the staff involved from the Booking and • Scheduling Team within Radiology. Additional learning is also being shared Trust-wide regarding how to access interpreters. Interpretation services have been included in the Monthly Quality Assurance audits. Question 38 currently reads: ‘Are Staff able to describe how they would access translator services?’. Additional information on how to access interpreters has been created to support staff awareness and learning. • Specifically, within the Radiology Department, it has been agreed that the booking clerk will oversee any translator booking as part of their role and administrative duties. This responsibility to book interpreters is a requirement of ward staff. An assurance review by the CCG in May 2022 has confirmed that all changes have been made. Future assurance reviews will be arranged to ensure that the changes have been embedded. I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. Trusts have been encouraged to review their systems and processes for interpreters to avoid a similar situation arising. This ensures that key learnings and insights around events, such as the sad death of Mr Bock, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director 2
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