Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0153, written 24 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 | 24 May 2022 |
|---|---|
| Reference | 2022-0153 |
| Deceased | Michael Wysockyj |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | The Queen Elizabeth Hospital, King's Lynn, 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS . REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Gayton Road King’s Lynn Norfolk PE30 4ET 1. CORONER I am Jacqueline LAKE, Senior Coroner for the area of Norfolk 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 06/10/2021 I commenced an investigation into the death of Michael Nestor WYSOCKYJ aged 66. The investigation concluded at the end of the inquest on 11/05/2022. The medical cause of death was: 1a) 1b) 1c) 1d) 2 Haemopneumothorax Ruptured Emphysematous Bulla Infective Exacerbation of Chronic Obstructive Pulmonary Disease Chronic Ischaemic Heart Disease, Diabetes Mellitus The conclusion of the inquest was: Mr Wysockyj died from a pneumothorax which was not identified until shortly before his death.. 4. CIRCUMSTANCES OF THE DEATH Mr Wysockyj had a significant medical history. On 20 September 2021 Mr Wysockyj felt very unwell and was taken by ambulance to Queen Elizabeth Hospital arriving at 18:28 hours. Due to the hospital being very busy, Mr Wysockyj was not taken into the hospital but was seen and assessed on the ambulance. He was admitted to Queen Elizabeth Hospital at 22:21 hours. A chest x-ray and a portable chest x-ray were not carried out as Mr Wysockyj was admitted to the Red Ward. Mr Wysockyj became increasingly restless and agitated which further delayed an x-ray being carried out. He received medication and personal care. At shortly before 02:00 hours it was recognised his agitation was due to low oxygen levels and Critical Care were contacted. At 03:55 hours radiography identified a large right sided pneumothorax. Shortly afterwards Mr Wysockyj went into cardiac arrest. Despite attempts at resuscitation, Mr Wysockyj was pronounced dead at 04:42 hours. 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 could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. This incident has been investigated by the Queen Elizabeth Hospital and much work has been put into place to prevent future deaths occurring. However, there do remain matters of concern. The matters of concern are as follows: 1. The ED was busy at the time and unable to offload ambulances. An x-ray cannot be carried out on an ambulance and must wait until the patient is in ED. If the patient remains on the ambulance for several hours this can delay the x-ray taking place. 2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an x- ray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place. This is something that can be missed in a busy department. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 18 July 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: – wife – daughter-in-law I have also sent it to: The Department of Health Care Quality Commission (CQC) HSIB Healthwatch Norfolk NHS England & NHS Improvement who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9. Dated: 24 May 2022 Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH
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.
The Queen Elizabeth Hospital Gayton Road Kings Lynn Norfolk PE30 4ET 13 July 2022 Mrs J Lake HM Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Dear Mrs Lake Regulation 28 – in the matter of Mr Michael WYSOCKYJ (deceased) Thank you for your report dated 24th May 2022 following the inquest into the death of Mr Michael Wysockyj. We set out our replies and action to the matters of concern you raised as follows: 1. The ED was busy at the time and unable to offload ambulances. An X-ray cannot be carried out on an ambulance and must wait until the patient is in ED. If the patient remains on the ambulance for several hours this can delay the X-ray taking place. Response: It is correct to say that an X-ray cannot undertaken on an ambulance because the radiology equipment that generates ionising radiation is insufficiently mobile and too large to be used in this setting. If it is thought by the assessing clinician who goes on to the ambulance that a patient’s need for an X-ray is urgent or an emergency, that patient will be prioritised to be removed from the vehicle as soon as possible. Although conditions for patients are not ideal whilst waiting to enter the Emergency Department, in this way their clinical needs in terms of urgent imaging remain the same as if the patient had already been transferred into the department. The physical constraints mean that this problem cannot be overcome in any other way other than by carrying out a careful clinical assessment on arrival on the vehicle during busy periods outside the Emergency Department including obtaining the relevant history from the ambulance crew. This process is already well embedded. 2. The need for an X-ray remains with the nurse, nurse in charge and or doctor. If an X-ray is not carried out, the request remains with the nurse, nurse in charge and or doctor and it was not clear from the evidence that there is anything in place to ensure this is escalated and the X- ray takes place. This is something that can be missed in a busy department. 13 July 2022 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Response: The Emergency Department does operate a system whereby two hourly rounds are conducted for patients in the department. This is carried out by the Band 7 nurse in charge and involves a checklist of clinical and other criteria to ensure that if clinically indicated, appropriate escalation takes place. The intention is that amongst all the other parameters if an investigation such as imaging or blood tests is awaited, these should also be escalated if there is a need to do so. However, it is correct to say that at the time of the inquest the check list contained no specific reference to investigations. The checklist has therefore been upgraded to include this (new version attached with the amendment highlighted). With this prompting, the Band 7 nurse in charge then goes back to the electronic ED record system (EDIS) because that already displays any outstanding investigations and whether they are overdue or have been carried out. There is a “red/green” system in place on a visible readout on the computer screen within EDIS whereby tests or radiology investigations which have not yet been completed can easily be identified by all clinicians. The Trust considers that this amendment to an existing process will be an additional safeguard to minimise the chances of the state of a patient's outstanding investigations being overlooked when there is high service demand in ED as well as the clinical support services they depend upon. The Trust remains very committed to reducing clinical risk as far as possible and has a sophisticated incident management system. Nonetheless we are committed to taking on board comments and observations from external observers to support that process, including HM Coroner’s office. We would be happy to assist further if any additional information is required. Yours sincerely Interim Medical Director Page 2 of 2
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