Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0377, written 25 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 | 25 Nov 2022 |
|---|---|
| Reference | 2022-0377 |
| Deceased | Joan Robinson |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Tameside and Glossop Integrated Care NHS Foundation Trust.
, Director of Nursing and Integrated Governance,
CORONER
I am Chris Morris, Area Coroner for Manchester South.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 3rd November 2022, I opened an inquest into the death of Mrs Joan Robinson, who died at
Tameside General Hospital, Ashton-under-Lyne on 30 June 2022, aged 88 years. The investigation
concluded at the end of the inquest which I heard on 23rd November 2022.
A post mortem examination concluded Mrs Robinson died as a consequence of:-
1a) Congestive cardiac failure;
b) Ischaemic and valvular heart disease with superimposed cervical spinal trauma following a
fall.
The conclusion of the Inquest was one of Accident.
CIRCUMSTANCES OF THE DEATH
Mrs Robinson was admitted to hospital having sustained multiple cervical spinal fractures in a fall at
her home. Following consultation with the regional neurosurgical centre, Mrs Robinson was treated
conservatively by means of immobilisation.
Shortly after her admission, Mrs Robinson developed acute confusion, and reported pain in her
throat. She was noted by nursing staff to have a poor oral intake, and eventually referred for a
dietician review. Whilst in hospital, Mrs Robinson lost her ability to swallow safely, and due to her
injuries and the treatment for it, difficulties were encountered in siting a nasogastric tube.
Having exhibited signs of atrial fibrillation just over a week into her admission, Mrs Robinson started
showing signs of congestive cardiac failure. Her condition worsened with increasing oedema, acute
kidney injury and a raised white cell count and a decision was made to institute palliative care.
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. The court heard evidence that, despite training on the Malnutrition Universal Screening Tool
being regarded by the Trust as ‘essential’, the completion rate of training within the
organisation is currently just 58.74%;
2. Connected with the above, it is a matter of concern that whilst the Trust describes this
training as ‘essential’ it is not deemed mandatory for completion by certain staff groups such
as nurses and healthcare assistants;
3.
It is a further matter of concern given the importance of adequate nutrition and hydration as
a part of basic patient care, that the Trust’s own internal investigation into the care and
treatment provided to Mrs Robinson has found that the ‘Nutrition and Hydration Committee
[is] not consistently supported, held or attended’.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation 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
20th January 2023. 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
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner, to
Robinson’s family, and to
of Weightmans LLP, solicitors to the Trust.
on behalf of Mrs
I have sent a copy of my report to the Care Quality Commission, 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.
Dated:
25th November 2022
Signature:
Chris Morris HM Area Coroner, Manchester South.
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