Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0324, written 17 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Oct 2022 |
|---|---|
| Reference | 2022-0324 |
| Deceased | Carl Wright |
| Coroner | Gordon Clow |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Other related deaths |
| Organisation named | Nottingham University Hospitals 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Nottingham University Hospitals NHS Foundation Trust Copies are to be sent to the family. 1 CORONER I am Mr Gordon Clow, Assistant Coroner for the coroner area of Nottinghamshire. 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 An investigation was opened touching on the death of Carl Wright on 3 November 2021. The investigation concluded at the end of the inquest on 28 September 2022. The conclusion of the inquest was the short form conclusion that Carl Wright’s death was from natural causes, with a supporting narrative as follows:- “There was sufficient information available for a suitably experienced doctor to ascertain that Mr Wright was suffering from an infection on or before 22 October 2021. This would have prompted investigations which would have identified the abscess earlier than 26 October 2021. This would, in turn, have improved Mr Wright’s chances of survival. It is not possible to say, on the available evidence, whether or not Mr Wright would have survived had this taken place.” 4 CIRCUMSTANCES OF THE DEATH On 4 June 2021 Mr Carl Wright underwent complex cardiac surgery against a background of previous stroke and other serious health conditions including diabetes mellitus, cerebrovascular disease and peripheral vascular disease. He suffered significant setbacks during and after the surgery and remained on the intensive care unit for approximately eight weeks. Mr Wright was transferred to a rehabilitation unit. The rehabilitation unit did not undertake the usual assessments and decision making prior to Mr Wright’s admission. Mr Wright was not sufficiently well to be safely cared for on the rehabilitation unit and his postural hypotension rendered him unsuitable for that form of inpatient rehabilitation. The unit itself was not well suited to Mr Wright’s particular needs. Whilst on the rehabilitation unit Mr Wright’s medical condition was not reviewed very frequently. Blood samples taken on 14 October 2021 showed evidence of an infection. No doctor reviewed these results at the time and no further action was taken in response. On 20 October 2021 Mr Wright began to demonstrate symptoms consistent with, but not clearly typical of, an infection. The medical care available to Mr Wright on 20, 21 and 22 October 2021 was limited to input from an inexperienced junior doctor. A 1 consultant could have been contacted by the junior doctor on the 20, 21 or 22 October 2021. The junior doctor did not contact a consultant for advice. Mr Wright’s symptoms during this period were caused by an abdominal abscess. Routine investigations which would have led to an earlier identification of the abscess were not undertaken. At no time during this period did the junior doctor responsible for Mr Wright’s care make any entries in the medical running records. This made it more difficult for other doctors to form a view about Mr Wright’s medical situation. Mr Wright’s medical condition was not reviewed as regularly as his condition indicated. The above factors delayed the diagnosis of Mr Wright’s infection and abscess. Mr Wright then went on to develop sepsis in response to the infection in the following days. By the time Mr Wright’s abscess had been identified, on 26 October 2021, he was too unwell, and the abscess collection was too irregular, for surgery or interventional radiology to be attempted. He was provided with appropriate care to maximise his comfort and then died on 29 October 2021. 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. The MATTERS OF CONCERN are as follows. (1) The majority of medical care, including the identification and assessment of deteriorating patients, was done by inexperienced junior doctors with no easy access to input from more experienced doctors; and (2) There was an established culture and practice of most blood tests results not being reviewed in a timely manner. Other areas of concern existed regarding other issues but plans were in place to address these areas and so I did not have ongoing concerns of a risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 13 December 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting 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 Interested Persons set out above. 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. 2 I may also send a copy of your response to any other person who I believe may find it useful or of interest. In this regard, I have sent a copy to the Care Quality Commission. 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 Mr Gordon Clow, HMAC 17 October 2022 3
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.
Please ask for the Medical Director’s Personal Assistant 8 December 2022 STRICTLY CONFIDENTIAL Mr Gordon Clow HM Assistant Coroner for Nottingham City and Nottinghamshire HM Coroner’s Court The Council House Market Square Nottingham NG1 2DT Medical Director’s Office 3rd Floor, Trust Headquarters City Hospital Campus Hucknall Road Nottingham NG5 1PB Dear Mr Clow Inquest: Carl Wright - Prevention of Future Death Report [PFDR] Response Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Wright. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Neurology Service, Surgical Division and more broadly in regard to medical management at the City Campus of NUH. The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight. Sub-Committees of our Boards will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust. Yours sincerely Medical Director [NUH] Enc Concerns identified through the PFDR Response to the concerns identified through the PFDR Immediate Actions Taken The Deputy Medical Director for Quality and Safety has met with the service to agree the below actions in response to the PFD. Access to input from more experienced doctors All patients who are planned to be transferred from an NUH in patient bed into Linden Lodge are now required to be physically assessed and reviewed by a Consultant from Linden Lodge, prior to transfer. This is to ensure that the patient is medically stable and suitable for transfer and for care within the Neuro-Rehabilitation Unit. The team are developing induction guidelines for junior doctors working in Linden Lodge, supported by an escalation process where a patient may be at risk of clinical deterioration [completion date 31/12/2022]. A Standard Operating Procedure [SOP] has previously been developed which outlines which medical speciality should be referred/escalated to at the City campus based on the presenting condition. For example, if postoperatively a City-based patient has signs of post-operative pneumonia the guidance means the responsible surgical team contacts the Speciality Registrar [SPR] for advice which in this scenario would be from the respiratory team, with the patient remaining under the care of the surgical team unless the respiratory team formally transfer the patient under their care. There are a small group of patients who do not clearly “fit” into this process, for example, presentations such as sepsis of unknown origin. For such patients the previous agreed process is that the on-call medical SPR would review the patient and seek telephone advice from the on-call medical consultant at the QMC campus and in rare circumstances transfer the patient to the QMC campus for ongoing management. The back up to this process is to contact the on-call consultant intensivist at the City campus Intensive Care Unit. Review of blood test results in a timely manner A SOP has been developed such that the review of all requested tests for patients are reviewed on a daily basis, supported by good documentation practice in the medical notes. This process has been built into the weekly ward round. Contingencies are in place if the weekly ward round is delayed or does not go ahead. Summary The actions set out above are intended to address the matters of concern identified in the Prevention of Future Deaths report in relation to ensuring that the medical care provided in Linden Lodge is delivered by appropriate experienced doctors supported by access to more experienced staff including the care of the deteriorating patient and the timely review of blood test results. I hope this response provides both you and the family of our commitment to learning from this case to significantly enhance the care of our patients.
See every Prevention of Future Deaths report matching Nottingham University Hospitals NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.