Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0351, written 4 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2022 |
|---|---|
| Reference | 2022-0351 |
| Deceased | Philip Day |
| Coroner | Alison Mutch |
| Coroner area | Manchester 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care CORONER 1 I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 22nd April 2022 I commenced an investigation into the death of Philip Geoffrey Day. The investigation concluded on the 19th October 2022 and the conclusion was one of Narrative: Died from complications of necessary medical therapy. The medical cause of death was 1a) Multi-organ Failure; 1b) Neutropenic Sepsis and Colitis; 1c) Methotrexate treatment of Psoriatic Arthritis 4 CIRCUMSTANCES OF THE DEATH Philip Geoffrey Day had psoriatic arthritis. He was prescribed methotrexate for his condition. Blood tests on 10th April 2022 showed that he had neutropenia and a raised CRP. He was advised to go to hospital due to the risk of neutropenic sepsis a rare but recognised complication of methotrexate. He went to Stepping Hill Hospital. Triage occurred approximately 50 minutes after his arrival and he was reviewed by a doctor at 04.56 almost 7 hours after his arrival. Antibiotics and fluids were prescribed for his neutropenic sepsis. This was outside the recommended timeliness guidelines. He was admitted to Stepping Hill Hospital and continued to be treated for neutropenic sepsis. He developed ileitis and colitis. He continued to be treated. On 15th April the combination of the neutropenic sepsis and inflammation led to a cardiac arrest and multi organ failure. He died at Stepping Hill Hospital on 15th April 2022. 1 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. – 1. When Mr Day arrived in ED, it was struggling to cope with a large backlog. Waiting times on that night /morning were significant. Triage wait times were approximately 1 hour. The time to see a doctor rose through the night to 7 hours and 38 minutes by 6am. The inquest heard that this was due to sheer volumes and that this is a situation that still arises. The impact is a delay in patients being seen, assessed and treated promptly; 2. In relation to Mr Day the inquest heard that the community OOH Doctor had correctly recognised the risk of neutropenic sepsis and had rung through to speak to a doctor at the hospital. At the inquest there was no documentation to assist in tracking that conversation or any evidence it had been recorded or acted on. It was clear from the evidence at the inquest that the sharing of information between community clinicians and secondary care was important and that there appears to be no recognised way for this to happened due to varied IT systems and no national recommendations for best practice in this scenario. As a consequence vital information is not available to ED teams. 3. The Inquest heard that Mr Day’s first EWS score in ED was 2. He did not trigger on EWS for sepsis. However the blood tests in the community had shown a very low neutrophil level and a rising CRP. Had those factors been recognised along with his immunosuppression then he would have been treated under the neutropenic sepsis pathway earlier. The evidence suggested that there is a lack of awareness of the guidance and red flags for neutropenic sepsis which delays treatment. Greater awareness and triage questions that prompt for neutropenic sepsis would reduce the risk of neutropenic sepsis symptoms being missed at triage. 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. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30th December 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 namely Mr Day’s Family and Browne Jacobson Solicitors, who may find it useful or of interest. 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 your response by the Chief Coroner. 9 Alison Mutch OBE HM Senior Coroner 04.11.2022 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.
From Helen Whately MP Minister of State for Care 39 Victoria Street London SW1H 0EU Alison Mutch Senior Coroner for the Coroner Area of Greater Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG 2 May 2024 Dear Ms Mutch, Thank you for your letter of 4 November 2022 to the Secretary of State for Health and Social Care Steve Barclay, about the death of Philip Day. I am replying as Minister with responsibility for urgent and emergency care. Please accept my sincere apologies for the significant delay in responding to this matter. I would like to assure you that the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Day’s death and I offer my sincere condolences to his family. I am grateful to you for bringing these matters to my attention. Your report raises concerns about to the treatment provided at Stepping Hill Hospital, Stockport NHS Foundation Trust. In preparing this response, my officials have made enquiries with NHS England (NHSE), local NHS services, and the Care Quality Commission (CQC). In relation to the concerns about the identification and early treatment of sepsis, NHSE is committed to finding ways to make awareness of the potential for sepsis, and the response to it, ever more consistent. The Academy of Medical Royal Colleges (AoMRC) has also issued advice to support decision making on the appropriate treatment of Sepsis. The AoMRC statement sets out that there is any clinical concern or laboratory evidence, such as blood tests, it encourages escalation regardless of the patient’s NEWS2 score. This is already reinforced in medical and nurse training widely, but the consistency of application in practice is key. NEWS2 is primarily for use in a hospital setting, and the need for an equivalent process in the community is recognised, and consideration of this is being taken forward. In relation to the concerns raised around the pressures in the emergency department and A&E waiting times, NHSE inform me that the local plan in place within Greater Manchester to help address A&E waiting times, includes upscaling primary care, increasing the number of 111 and 999 call handlers, improving the use of the directory of services and navigation of alternatives to A&E, and to provide better home support to help reduce pressure on hospital bed capacity and enable faster patient flow through hospitals. Locally work is underway to create a shared care record across primary and secondary care meaning pathology results will be able to be viewed along with clinical reviews whether undertaken in a community or hospital setting. I have asked officials to further raise the processes for information sharing between community out-of-hours services and emergency departments, with NHS England 1 The CQC has also considered your report and will continue to monitor waiting times in emergency departments, delayed admissions and waiting times for surgery with regular trust engagement on ongoing risks and pressures. I recognise the pressures our A&E services are facing and the impact on waiting times for patients. That is why we published our 2-year Delivery plan for recovering urgent and emergency care services in January 2023, which aims to deliver sustained improvements in emergency waiting times. The ambition is to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025. A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 billion of dedicated funding. Further, we also achieved our target of scaling up virtual ward beds to over 10,000 in advance of winter. We recognise that a whole-system approach is needed to ensure people get the emergency care they need when they need it. This is why we have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E. We have seen improvement in A&E waiting times this year following the Delivery Plan’s publication. National A&E 4-hour performance improved by 3.3ppt to 74.2% in March 2024 from 70.9% in February 2024, and up from 71.5% in March 2023. However we recognise there is more to do, and reducing waiting times is a priority for this Government. Thank you once again for bringing these concerns to my attention. Yours, HELEN WHATELY
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