Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0404, written 13 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Dec 2022 |
|---|---|
| Reference | 2022-0404 |
| Deceased | Yvonne Rankin |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Cardiff and Vale UHB 2. Chief Executive, Abbott Nutrition 1 CORONER I am Rachel Knight, Assistant Coroner, for the South Wales Central Area 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 20th January 2021 I commenced an investigation into the death of Yvonne Dian Rankin, aged 68. The investigation concluded at the end of the inquest on 6th December 2022. The conclusion of the inquest was a narrative. The cause of death was recorded as follows: 1a. Septic Shock 1b. Abdominal wall abscess at and below the PEG site (operated) 1c. Squamous cell carcinoma right tonsil II: Type 2 diabetes 4 CIRCUMSTANCES OF THE DEATH Yvonne Rankin was aged 68 when she died at the University Hospital of Wales on 14th January 2021. Yvonne was suffering with throat cancer and undergoing radiotherapy. She had been fitted with a PEG to enable nutrition, medication and fluids to be administered. Despite good care of it, her PEG site became infected with bacteria and a fungal infection which was initially treated and improved. However, an infection returned, and Yvonne quickly developed sepsis. Sadly, despite extensive medical treatment she died. 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) although family and Yvonne were told that they could refer any concerns to various professionals including the Abbott nurse, they did not understand the specific signs of sepsis to watch out for; (2) had family understood the signs of sepsis, it is likely that they would have rung 1 999 much sooner; and (3) It may be that patient/carer information cards setting out the common signs of sepsis already exists. Would it be possible to give out such information cards to patients/carers with PEGs and/or those with a known risk of infection who are in the community? 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7th February 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to family of Yvonne Rankin and her Abbott nurse, who may find it useful or of interest. 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. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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 DATE: 13.12.22 Rachel Knight Assistant Coroner 2
2 responses 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.
A880TT NUTIIITION Abbott Laboratories Lt<l ,\bboll House Vnnwall llu~iness Pm-k Vnnwall Ru.id Maidcnht'ad $1.6 4XF. a Abbott Private and Confidential Ms RKnight Assistant Coroner Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF37LJW 7 February 2023 Dear Ms Knight Abbott response to Regulation 28 Report (ref: 323219) dated 13 December 2022 (the "Regulation 28 Report") For clarity, the Abbott Nurse Advisor team is employed by CHASE and, on behalfofAbbott Laboratories Limited (Abbott), their role is to fulfil an enteral feeding nursing service. as part of an NHS Contract Specification. Abbott currently holds an enteral feeding contract with Cardiff and Vale University Health Board (Cardiffand Vale UHB). In accordance with the existing contract specification between Abbott and Cardiff and Vale UHB, the Abbott Nurse Advisors (the ANAs) are only permitted to issue patient information as authorised by Cardiff and Vale UHB. Abbott and Cardiff and Vale UHB reviewed how the requirements of the Regulation 28 Report can be met and the following has been agreed between the parties on 3 February 2023: Cardiff and Vale UHB have updated their current patient information provided to new patients with PEGs to include the signs of sepsis. Document updated 30 January 2023. WWW.ABBOTT.CO.UK This updated information will be provided to patients and their family/carers by Cardiff and Vale UHB from 6 February 2023. The ANA team will carry a supply of this updated literature and ensure that any new patients they see have this information. If they do not, the ANA will supply this. We anticipate that this will be implemented by the ANA team by 1 March 2023 (upon receipt from Cardiff and Vale UHB). Cardiff and Vale UHB will purchase Adult and Paediatric Symptom Cards (cards with the symptoms of sepsis). This information will be given to any patients who present with signs of an infection with copies shared with relevant family members/carers. The ANA team will carry a supply of these cards (to be initially provided by Cardiff and Vale UHB) and ensure that they are shared if any patients present with signs of an infection. Adult and Paediatric Symptom Cards ordered by Cardiffand Vale UHB on 3 February 2023. We anticipate that this will be implemented by the ANA team by 1 March 2023 (upon receipt from Cardiff and Vale UHB). C Yours sincerely Healthcare Services Director Abbott Laboratories limited - Nutrition Division Cc: Chief Executive, Cardiff and Vale UHB Page 2of2
Bwrdd lechyd Prifysgol ,-Q GIG Caerdydd a'r Fro oOo NHS ' U-- Cardiff and Vale Universit y Health Board WALES Executive Headquarters / Pencadlys Gweithredol Woodland House Maes-y-Coed Road Cardiff CF14 4HH Ty Coedtir Ffordd Maes-y-Coed Caerdydd CF14 4HH Eich cyf/Your ref; 323219 Em cyf/Our ref: SR·jb-0223-9937 Welsh Health Telephone Network: Direct Line/Ulnell uniongychol : 029 21B3 6010 3 February 2023 Private and Confidential Ms Rachel Knight Assistant Coroner Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF371JW Dear Ms Knight Thank you for your letter of 19 December 2022 received on 29 December 2022, in which you have shared the Regulation 28 with associated actions for improvement following the inquest into the sad death of Ms YDR aged 68 who passed away on 14 January 2021. I note that whilst the conclusion was narrative it is your view that some actions could be taken by the Health Board to minimise the risk of future deaths in similar circumstances. (_ From your findings it became evident that the family of the deceased had not been suitably alerted to the signs and symptoms of sepsis and if they had been made aware of the "red flags" they may have contacted staff sooner. In order to review the pathway of communication we have held several multidisciplinary meetings to consider the communication provided and to discuss where improvements could be made. I note that Abbott will respond to you under separate cover. the Health Board and Abbott have worked together to consider the most appropriate improvements across the communication pathway as people move through their journey of care. The eCORFLO booklet (Information for patients, relatives and carers, Gastrostomy feeding tube, Percutaneous Endoscopic Gastrostomy) the patient is given at time of the procedure has been updated to reference to sepsis (attached as Appendix One). People will also be given an additional information sheet if an early discharge occurs (attached as Appendix Two). The booklet and information sheet are in use. 6wrdd lec:hyd Pnfysgol Caerdydd ~·, FtQi yw enw gweith~OI Bw vrdd l echyd U.al Psify'9ol CatrdyOd a'r lllro Drd1ff and Vale University Health Board i1, th• opcratianal name of C:Jrdiff and Vale Unlve,,ity Local Healtll 8~rd C,oesawir y 9wtd<1~ lh yn G~ neu Sao$1H1P ~n tiY"(J(Jwn yn cJlfa.lhr8'bu, chi yn elChdelol,U llHth Ni fydd gohebu _yn Gymmog ynaou unfhywo«J, , ,,. Bo.d~fc:on-.~nc.,,, W.,rih o,r Engli.sh. W• w•~'""Wit.... oommurwc.e,~ it1 )'OINCIIOsM ' •~ - c«r..~nc• Ht Wfflll wilrrotWedlO. O.lay In addition, we are considering suitable generic information to be given both at time of procedure and later in the community we are considering the SEPSIS awareness credit card size information. This will then be able to be used across wider areas, it gives simple clear information and is a highly visible card. We care for approximately 450 enterally fed patients within the UHB (not all with gastrostomies) so dietetics would purchase these so they could be issued at initial discharge as well as in the community when needed. Adult Symptom Cards I The UK Sepsis Trust The patient can keep this with them and there is evidence that alert cards work quite effectively. We will in addition ensure a sepsis card is also given to children and their parents. We will use the Paediatric Symptom Cards I The UK Sepsis Trust to promote awareness of the signs and symptoms of children who are developing sepsis. We will commence use of the cards as soon as possible. r We will advise the other Welsh health board dietetic teams of actions taken in response to the Regulation 28 for their consideration as an all Wales approach would be helpful. In summary Cardiff and Vale UHB will update the current patient information provided to new patients with Percutaneous Endoscopic Gastrostomy to include the signs of sepsis. This updated information will be provided to patients and their family/carers by Cardiff and Vale UHB. The Abbott Nurse Advisors team will carry a supply of this updated literature and ensure that any new patients they see have this information. If they do not, the Abbot Nurse Advisor will supply this. I hope that this information is helpful and offers the assurance you are seeking regarding the improvements instigated to ensure patients and their families in similar circumstances to Ms R will be provided with the relevant information to consider the signs of sepsis at the earliest opportunity. Yours sincerely Chief Executive Encs: Appendices One and Two 8 w,dd IKhVd Pl'\fylGOI CH:1dvdd a•., Fro yw ~w gwetth'4dol Bwyrdd lechyd Ueol Prtfysgo1 ~ erdydd a'r Fro C.rdjff' end VeiJe Unlvers.lty M11k h Baud 1, tt\e CCH! raUonal name or and Vele un1ver11ty LOUI Htallh Board Crotuwity8wld<l°'"'°'8olh )'n G)ffllNS!neuS.tes,,egi ~nbyddwnyn,;fell~achiynH:hOCtwisieith Nifyddgohebuyt1GJlfflfN'1)1ftet'&uur>.r'hywoed, Tr,e- 8otMTJ wekc>tNs f.O"'HPOnd•nc• dt w~ t!JI English WIit wiO 4MSUl'lt lhel wlill~ ,.. kl ,oa.... chose-n '.ng~ Cone~nc• NII W•Wi .;,"°' ..aJo. d9l.-y
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