Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0137, written 10 May 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 May 2022 |
|---|---|
| Reference | 2022-0137 |
| Deceased | Freda Lennox |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Ashford and St Peter's Hospitals NHS Foundation 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Freda Mary Lennox A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: • Chief Executive, St Peter’s Hospital • Medical Director, St Peter’s Hospital 1 CORONER Dr Karen Henderson, HM Assistant Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST On 5th May 2021 I commenced an investigation into the death of Freda Mary Lennox. On the 4th October 2021 I concluded the Investigation. The medical cause of death given was: 1a. Cor Pulmonale 1b. Pulmonary Hypertension 1c. Interstitial Lung Fibrosis 2. Elective Right Hip Replacement I determined that Freda Mary Lennox died as a consequence of natural causes hastened by an operative procedure 4 CIRCUMSTANCES OF THE DEATH Mrs Lennox was an 86-year-old lady with multiple medical comorbidities with a significant history of idiopathic pulmonary fibrosis which restricted her activities of daily living leaving her house bound and requiring long term oxygen therapy. Mrs Lennox was initially scheduled and then cancelled for an elective total hip replacement in November 2018 and May 2019 before being admitted to St Peter’s Hospital on 2 nd November 2020 for the procedure. She was informed of and understood that this was a high-risk procedure for which she gave consent. At the end of the surgical procedure, she had a cardio- respiratory arrest from which she was initially successfully resuscitated and admitted into the intensive care unit. Despite such support, she did not rally and died at 04.07 hours on 4 th November 2020. 5 CORONER’S CONCERNS 1. Mrs Lennox had previous pre-operative assessments in 2018 and 2019 and a respiratory review in February 2020. Following a telephone consultation in September 2020 an echocardiogram was requested for pulmonary hypertension and/or the development of Cor Pulmonale but this had not been carried out prior to her surgery. look to 2. Mrs Lennox had not been recently reviewed by the consultant orthopaedic surgeon prior to her admission on 2 nd November 2020 despite her medical co-morbidities having given rise to concerns as to her suitability for an elective total hip replacement. 3. The consultant anaesthetist was not informed about Mrs Lennox and her medical co-morbidities prior to her admission. Nonetheless the consultant anaesthetist undertook a thorough pre-operative assessment on the day of surgery and Mrs Lennox consented for surgery. 4. Evidence was heard that there was a lack of funding for a dedicated high-risk consultant led anaesthetic pre-operative assessment clinic with the necessary equipment to be able to suitably risk assess patients prior to any potential surgery. 5. There was no designated (permanent) room space to set up such a clinic and no secretarial input to type reports for high-risk patients which led to a significant delay in providing a timely service. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following: 1. See names in paragraph 1 above In addition to this report, I am 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 at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: Karen Henderson DATED this 10th Day of May 2022
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.
r,•1:kj Ashford and St. Peter's Hospitals NHS Foundation Trust St Peter's Hospital Guildford Road Chertsey Surrey KT16 0PZ DX 119775, Chertsey 2 Our Ref: CC2515 Date: 5 July 2022 Ms. Karen Henderson Assistant Coroner for Surrey HM Coroner's Court Station Approach Woking GU22 7AP Dear Ms Henderson Re: Mrs Freda Mary Lennox Regulation 28 Report to Prevent Future Deaths Please find below my responses to your concerns raised in your email received on 11 May 2022 following the inquest into the death of Mrs Freda Mary Lennox. The Regulation 28 report sets out the matters giving rise to concern numbered 1-5 below. 1. An echocardiogram was requested September 2020 but was not carried out prior to her surgery. 2. No recent review by consultant prior to admission on 2 November 2020 despite medical co-morbidities giving rise to concern over suitability for elective total hip replacement. 3. The consultant anaesthetist was not informed about Mrs Lennox and her medical co- morbidities prior to her admission. Nonetheless the consultant anaesthetist undertook a thorough pre-operative assessment on the day of surgery and Mrs Lennox consented for surgery. 4. Lack of funding for a dedicated high-risk consultant led anaesthetic pre-operative assessment clinic with the necessary equipment to be able to suitably risk assess patients prior to any potential surgery. 5. There was no designated (permanent) room space to set up such a clinic and no secretarial input to type reports for high-risk patients which led to a significant delay in providing a timely service. The Trust has appointed an anaesthetic lead for high-risk anaesthetic patient pathways, and in response to your concerns we have finalised our plans to expand the services for high-risk patients. We now have four dedicated fully functioning high risk anaesthetic pre-assessment clinics per week. The clinics are led by consultant anaesthetists with a specialist interest in pre- assessment and high-risk patients, one of which is an orthopaedic anaesthetist whose clinics focus on high-risk orthopaedic patients. Additionally, clinics are protected in consultant job plans, and the estate resources such as appointment rooms with appropriate medical equipment are also protected. ,.,,:kj Ashford and St. Peter's Hospitals NHS Foundation Trust During these clinics there is the opportunity to follow up on any outstanding tests in good time prior to any planned surgery, discuss the detail of any anaesthetic risk with the patient and answer any questions they may have. The Trust introduced an electronic patient record system in 2022, called Surrey Safe Care (SCC). We have created a specific SSC pathway for referral into the high-risk clinic that sits separately to the standard pre-operative assessment referral pathway. This requires a referral by a consultant surgeon. The SSC system also allows for a range of formalised patient risk assessments and recognised scoring systems individualised to the patient as appropriate. These risk assessments are visible to all relevant staff with the aim of adequately informing anaesthetists and others, pre-operatively about their patient's risk status. The Trust expects the current funding for consultant led dedicated high risk anaesthetic clinics to continue and these will likely expand in the future. I do hope the details of the changes the Trust has made to our practices are sufficient to allay the concerns you have raised in your report. Please do not hesitate to contact me should you require further details or documentation. Yours sincerely Medical Director
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