Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0199, written 27 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2022 |
|---|---|
| Reference | 2022-0199 |
| Deceased | David Hulme |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS 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.
OFFICIAL Ian M Arrow Her Majesty's Senior Coroner for the County of Devon Plymouth, Torbay and South Devon Coroner Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, University Hospitals Plymouth, NHS Trust, Chief Coroner CORONER I am Ian Arrow, Senior Coroner for Plymouth Torbay and South Devon 2 CORONE~SLEGALPOWERS 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. u k/u kpga/2009/25/schedu le/5/parag raph/7 http://www. legislation. gov. uk/uksi/2013/1629/part/7 /made 3 INVESTIGATION and INQUEST On 27 June 2022 I heard an Inquest touching the death of David Anthony Hulme. I recorded a narrative conclusion, namely:- The deceased had a history of chest symptoms. In particular he had a right pulmonary abscess. On 12 June 2020 he underwent a right thoracotomy for pneumonectomy. Histology by a regional hospital pathologist confirmed this as sarcoidosis. the It became clear Histopathologist referred the case to The National Centre of Excellence for lung conditions, a second Hospital Trust. the deceased was deteriorating On 25 January 2021 further. On 1 February 2021 the deceased's wife reported worsening symptoms. On 10 February 2021 the second Trust indicated suspected B Cell Lymphoma. The samples were sent for a third opinion. On 15 February 2021 a supplemental report was issued by the third Trust. On 16 February 2021 a supplemental report was issued by the second trust. All this time the deceased remained on the Intensive Care Unit. The further opinions indicated a condition known as Lymphoma. The deceased was treated for Lymphoma. The deceased's condition deteriorated. A discussion not to resuscitate was had on 3 March 2021. The deceased died on 6 March 2021. His cause of death was Lymphoma a naturally occurring condition. I heard evidence from a Consultant Pathologist that her Pathology Department was under si~nificant pressure of work and in her opinion was understaffed. OFFICIAL I heard evidence from the Hospital Trusts Pathology Manager that he had prepared a business case for the additional appointments of Consultants. 4 CIRCUMSTANCES OF THE DEATH Please see above 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. - I am concerned that the Pathology Department remains significantly under resourced. I ask you please to:- (1) Review the Consultants staffing levels in the Pathology Department particularly those Consultants dealing with Thoracic work so as to ensure timely and accurate diagnosis of conditions at this regional centre. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 August 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. I have also sent it to the family. 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 y6ur response by the Chief Coroner. 9 Dated 27 June 2022 Signature / /,' ,.Y/ c·. Ci ~·· L·-··•--.J ·enior Coroner , I M Arrow, Plymouth, Torbay and South Devon
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.
Professor Mark Hamilton MBBS BSc FRCA FFICM Chief Medical Officer Department of Clinical Management, Level 07 University Hospitals Plymouth NHS Trust Derriford Road Plymouth PL6 8DH Tel. 01752 439488 E Mail : markhamilton@nhs.net www.plymouthhospitals.nhs.uk 13th July 2022 Mr I Arrow HM Coroner 1 Derriford Business Park Breast Road Plymouth PL6 5QZ Sent by e mail to HMCoroner@plymouth.gov.uk Dear Mr Arrow Re : Inquest touching the death of David Hulme ; Inquest Date – 27/06/2022 At the conclusion of the above referenced inquest, you determined that under the powers granted to you by paragraph 7, schedule 5 of the Coroner and Justice Act 2009 and Regulations 28 and 29 of the Coroner (Investigations) Regulations 2013 that you would write to University Hospitals Plymouth NHS Trust (UHP) with a Preventing Future Deaths Report. We have now received that report and note your concerns are as below: “I am concerned that the Pathology Department remains significantly under resourced. I ask you please to: (1) Review the Consultants staffing levels in the Pathology Department particularly those Consultants dealing with Thoracic work so as to ensure timely and accurate diagnosis of conditions at this regional centre” As part of the inquest process UHP provided you with a copy of the Root Cause Analysis Report (RCA) which identified the need for additional Consultant resource within the Pathology Department to which your concern is directed. The evidence submitted both within the RCA and via a further report, authored by the Pathology Operations Manager, confirmed that the business case to appoint further Consultants into the Pathology Department had been approved with funding allocated to this end. It was stated that the recruitment process would commence as soon as possible. Working in Partnership with the Peninsula Medical School Chairman: Richard Crompton Chief Executive: Ann James I can confirm that UHP have approved the funding for 4 x Consultant Pathologist posts and whilst we cannot guarantee a date that these posts will be filled, we hope to recruit into these posts as soon as possible and are in an active recruitment phase. We would ask you to note however that there is a national shortage of suitably qualified clinical staff practicing in this field and thus whilst we shall pursue these appointments with our best endeavours the recruitment may be a protracted process. Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall. We trust this response can assure you of our commitment to providing a suitably staffed Pathology Department and our commitment to the safety of all patients within the whole South West region. Yours sincerely Professor Mark Hamilton Chief Medical Officer for UHPNT Visiting Professor University of Plymouth Faculty of Health Page 2 of 2
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