Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0253, written 11 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Aug 2022 |
|---|---|
| Reference | 2022-0253 |
| Deceased | Katie Horne |
| Coroner | Andrew Harris |
| Coroner area | London Inner (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 REPORTS TO PREVENT FUTURE DEATHS 1. CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction 2. CORONER’S LEGAL POWERS I make these reports under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. INQUEST On 12th October 2021 an inquest into the death of Ms Katie Horne was opened. She died on 11th April 2020 in King’s College Hospital, London. (case ref: 11833245) The inquest was concluded by me on 10th August 2022 with a conclusion of natural causes. 4. CIRCUMSTANCES OF THE DEATH Ms Katie Horne presented to Princess Royal (PRH) A&E department in Sussex with jaundice on 1st March 2020. She was diagnosed as having hepatitis and investigated as an outpatient. Her liver function tests were monitored and deteriorated. Viral antibody test results available on 9th were not identified by doctors until the 16th when her liver function tests were: bilirubin 493 and ALT 1439 and when a gastroenterologist was first consulted. She was admitted to PRH on 18th due to concerns of incipient liver failure. Her care was reported to and monitored by Kings College Hospital liver unit (KCH) from 18th, but she was not transferred earlier as the first wave of the Covid pandemic limited the capacity of KCH to provide care. Her blood tests showed that liver biopsy was not possible at this stage and on 20th she was begun on steroids on the (correct) assumption she had auto- immune hepatitis, but she proved to be steroid resistant. She was transferred to KCH for consideration of liver transplantation on 24th. By 30th she was found to be Covid positive which according to the best international guidance at the time was a contraindication to transplantation. She developed Covid pneumonitis and died at 05.22 on 11th April. 5. 6. This REPORT IS BEING SENT TO: Road, Haywards Heath, West Sussex, RH16 4EX , Chief Executive, Princess Royal Hospital, Lewes THE CORONER’S MATTER OF CONCERN Despite multiple attendances as an outpatient with deteriorating hepatitis, it took 15 days for crucial blood test results to be seen by the doctors (in part due to lab backlog but there was no evidence of any doctor prioritising or chasing the results) or for a gastroenterologist to be consulted on care. This led to a liver biopsy not being possible (in part as her blood clotting had deteriorated) and later than necessary commencement of steroid therapy and consequent later referral for liver transplantion at Kings College Hospital. Although it was suggested that these failures in care were associated with the capacity of the hospital to deliver services in the first wave of the pandemic, there was little evidence to support or refute that. . ACTION SHOULD BE TAKEN 7. The case is brought to the attention of the hospital as there was no internal investigation, review or action plan to see whether these problems had resolved or were systemic. 8. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 7th October 2022. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, 9. COPIES and PUBLICATION I have sent a copy of my report to the following interested persons: (parents) , AVMA (for Kings College Hospital), Legal Director, Hill Dickson LLP I am also copying it to Rt Hon Baroness Heather Hallett DBE, Chair of the UK Covid 19 Inquiry, noting that the ability of one hospital to perform a liver biopsy, and another to admit in a timely manner to the liver unit and to conduct transplants were all materially affected by the pandemic, quite separately from the fact that Katie acquired the virus. I am also copying this to and The Care Quality Commission, who may have interest in the matter. I am also under a duty to send the Chief Coroner a copy of your response. He 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. 10. [DATE] [SIGNED BY CORONER] 11th August 2022 A N G Harris, Senior Coroner
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.
University Hospitals Sussex NHS Foundation Trust Mr Andrew Harris Senior Coroner London Inner South Southwark Coroner's Court 1 Tennis Street Southwark SE1 1YD University Hospitals Sussex NHS Foundation Trust Trust Headquarters Royal Sussex County Hospital Eastern Road Brighton BN25BE www.uhsussex.nhs.uk 4 October 2022 Dear Mr Harris Inquest into the death of Katie Louise Horne - Regulation 28 report Thank you for the letter from your clerk of 31 August 2022, enclosing your Prevention of Future Deaths report. Firstly, I wish to convey my deepest condolences to Katie's family on her tragic death. I am acutely aware that my response will not bring Katie back, or lessen the pain that Katie's parents feel, however, I hope they can take some small comfort in how seriously we have taken her death and the improvements that we have made. Although the delays at the Princess Royal Hospital did not cause Katie's tragic death from covid, I can assure you that Katie's case received senior oversight prior to the inquest as part of the complaint investigation and discussion at our serious incident review group, and it continues to do so. My response below summarises the actions we have taken, and the improvements we have made. The Chief of Service for the Division of Medicine confirms that the Acute Medicine service at the Princess Royal Hospital was set up in early March 2020 in response to the covid pandemic. As such, the service was predominantly run by a locum Consultant. However, we now provide, at a minimum, a substantive acute physician and geriatrician at the Princess Royal Hospital site every weekday, and the weekends the care and management is provided by the substantive general physicians. Ambulatory care, instead of running out of a small room next to the Emergency Department, as it was in March 2020, is now situated in a large area connected to the Acute Medical ward, with its own dedicated nursing, administrative, and medical staff. This shares the same clinical governance and standard operating procedures as the main ambulatory care area at the Royal Sussex County Hospital in Brighton. On§LQfthe~keystandard~operating procedu,res now in place is that any patient whose problem is not resofvable-withJnJWQ visifaJo Jhe emer§ency aml5T.ilatory care Llni( must be-referred to the ap_12roj)riate specialist service - this rufe was operaUonalat the Royal Sussex County Hospital in March 2020, bufff liad not at that time been set up at the Princess Royal Hospital. I can assure you that it is in place and regularly reviewed by the Division to ensure it is working. Our Lead Consultant for Acute Medicine & Same Day Emergency Care has confirmed the following important changes we have made: 1. The Acute Medicine team now manage the rapid access medical unit (RAMU). A business case has been submitted for additional administration support for RAMU at the Princess Royal Hospital, in line with our service at the Royal Sussex County Hospital. 2. We now have a virtual environment which allows for the tracking of outstanding patient investigations, including blood test results. 3. We have established a Gastroenterology 'hot clinic' (urgent new presentation clinic), which ensures referral of all jaundice patients after their initial assessment and ultrasound scan. This 'hot clinic' is run by the Gastroenterology Registrars with Consultant support. Our Lead Consultant Gastroenterologisthc1s gonfirmed thatther~ar~ sp~c::ialiststaff available ?_aays .9. we,~l(fo contaafc>r advice. Furthermore, we now have a digital enhanced cordless technology (DECT) 'phone (in addition to the normal bleeps and mobile telephones) which the Gastroenterology Registrars carry to ensure they are contactable. The Gastroenterology Bleep number/DECT 'phone number is in the directory on the Induction app which all junior doctors are provided with. I can confirm that it is extremely unlikely there would be a similar delay in the future, as after initial assessment, the patient is now referred to Gastroenterology 'hot clinic' with their autoimmune profile pending. The Gastroenterology 'hot clinic' team arrange appropriate assessment, likely in person, at the Emergency Ambulatory Care Unit (EACU) at the Royal Sussex County Hospital, and they ensure that all the relevant test results are available from the laboratory. To ensure wider learning and sharing of the changes and improvements we have made, the c::ase has_p~E:l!J.PI.esented(anonymously)atour monthly Patient Safety Group which has a wTcTe attendance of staff from all our hospitals. ·····. Our services were under extreme pressure in March 2020 due to the first wave of the global covid pandemic. I hope the changes we have made since, set out in this response, provide you with assurance and confidence in our service. We strive to continually learn and improve the services we provide to our patients. My thoughts are with Katie's family and friends. Yours sincerely, Chief Executive
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