Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0033, written 31 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2023 |
|---|---|
| Reference | 2023-0033 |
| Deceased | David Nash |
| Coroner | Abigail Combes |
| Coroner area | West Yorkshire (Eastern) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England – Primary Care Complaints Team 1 CORONER I am Abigail Combes, assistant coroner, for the coroner area of South Yorkshire (West District) hearing this case on behalf of West Yorkshire Eastern. 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 13 November 2020 an investigation commenced into the death of David John Nash born on 26 August 1994. The investigation concluded at the end of the inquest on 20 January 20223. The conclusion of the inquest was:- David died on 4 November 2020 at Leeds General Infirmary as a result of a brain-stem infarction, arising from a cerebella abscess caused by mastoiditis. On 2 November 2020 there was a missed opportunity to direct David to seek face-to-face care during his GP appointment that morning. Had he been directed to seek face-to-face or urgent care by the GP Practice it is more likely than not that he would have undergone neurosurgery approximately 10 hours earlier than he actually did; which at that time it is more likely than not would have been successful. The medical cause of death was: 1a: Brain-stem infarction 1b: Cerebellar abscess 1c: Mastoiditis 4 CIRCUMSTANCES OF THE DEATH 1. David first spoke to his GP on the phone about some swollen lumps on his neck on 14 October 2020. He was advised that he should have blood tests and these were booked for 2 November 2020. 2. On 23 October 2020 he further sought advice from the GP because he had pain in his ear and was complaining of an ear infection. At this telephone appointment there was an assessment for mastoiditis and otitis externa was diagnosed. Antibiotic ear drops were prescribed. 3. He was then spoken to on the phone again on 28 October 2020 because he felt that he had blood in his urine. He was advised to deliver a urine sample to the Practice which he did and when tested contained blood and white cells resulting in further antibiotics being prescribed. The view of the GP expert was that this was unlikely to be a UTI however there would be no basis on which a GP would link these symptoms to mastoiditis and therefore the treatment was not unreasonable on this occasion. 1 4. From the evidence of , ENT consultant it is more likely than not that at some point in the days after this appointment, David began to develop the abscess that would ultimately prove fatal. 5. On 2 November 2020 David had a telephone consultation with an ANP at his practice. He had continued fever, pain behind his eye and sinus pain. He had had a negative covid-19 swab in the week prior to this appointment but nevertheless his blood tests were cancelled and he was advised not to visit the surgery but to take a further Covid-19 swab and await the results. This clearly unsettled David who was concerned to get his blood tests completed and the ANP gave reassurance that as soon as he had a negative covid-19 swab she would book him in for his blood tests and see him urgently in practice. 6. As the 2 November 2020 progressed David became increasingly unwell. This resulted in David's partner contacting NHS 111. She explained his symptoms and was advised that a clinician would call back within 6 hours. Unfortunately David then vomited and so his partner called NHS 111 again and was given the same advice. When a clinician did call David's partner was advised not to wake him if he was sleeping and to keep up to date with the codeine pain relief. About an hour later David began to be disorientated and his partner made a final call to NHS 111 resulting in an ambulance being called. 7. David was placed on the dental pathway for NHS 111 which meant that he missed the opportunity to be asked questions which may have identified mastoiditis. However this pathway at the time was not unreasonable for him on the basis of his symptoms. 8. David was taken to St James' Hospital initially. He was triaged quickly and a working diagnosis of either meningitis or encephalitis was made. Both of these conditions would be treated at St James'. He required a CT scan which was undertaken just over 2 hours after it was booked. This was within the context of an ED suffering significant pressures. 9. As soon as the CT scan was undertaken it was apparent how unwell David was and urgent steps were taken to transfer him to the LGI for neurosurgery. 10. Unfortunately whilst David was in the resuscitation part of ED he deteriorated very significantly and suffered a fall resulting in head lacerations. This fall did not contribute to his death but nevertheless represented an acute deterioration in his condition with his GCS going from 10 to 3 and requiring immediate ventilation. 11. David survived to the LGI and underwent surgery to insert an external ventricular drain. This appeared to be a successful procedure at first and David responded however he continued to deteriorate over the course of the 3 and 4th of November 2020 and clinicians determined that his condition was unsurvivable. 12. David died at the LGI on 4 November 2020. 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: – I heard evidence that David's father made a complaint to NHSE about the primary care service, namely the GP Practice, that David had had contact with. This resulted in a clinical review of that complaint by Dr D'Souza which was initially highly critical of the 4 2 occasions of care which David had at his GP Practice (listed above) It appears that this complaint was handled without a clinical rationale from the GP Practice being provided which resulted in reviewing his opinion once that information was provided in the anticipation of inquest proceedings. I heard evidence from the GP Practice that they were not made aware of the concerns raised by until the inquest process had disclosed these concerns. I am unclear how the primary care complaints team ensure that the details from their clinical reviews are fully informed taking account of information provided from complainants and those involved in the clinical management of a patient and how that information is then shared back to the practice to ensure appropriate learning can be undertaken. I am also not clear of the process of cascading this information to the primary care network in general where that is appropriate to raise awareness of an issue or condition for example. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation 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 Tuesday 28th March 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 the following Interested Persons: Mr and Mrs Nash and Burley Park GP Practice. 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. In this case I have sent a copy of this report to NHS West Yorkshire ICB as the organisation which will take on responsibility for primary care complaints in 2023. 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 Signed: Dated: Tuesday 31st January 2023 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.
Ms Abigail Combes
On behalf of:
County of West Yorkshire (Eastern District)
Coroner’s Office and Court
71 Northgate
Wakefield
WF1 3BS
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
25 April 2023
Dear Ms Combes,
Re: Regulation 28 Report to Prevent Future Deaths – David John Nash who
died on 4 November 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated
Tuesday 31 January 2023, concerning the death of David John Nash on 4 November
2020. In advance of responding to the specific concerns raised in your Report, I would
like to express my deep condolences to David’s family and loved ones. NHS England
are keen to assure the family and the coroner that the concerns raised about David’s
care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused to David’s family or friends. I realise that
responses to Coroner Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones and appreciate
this will have been an incredibly difficult time for them.
Your Report raised the following concerns over how complaints made about the
primary care service provided to David were handled:
1. That the complaint was handled without a clinical rationale from the GP
Practice being provided which resulted in the clinical reviewer revising their
opinion once that information was provided in the anticipation of inquest
proceedings.
A review of our records indicates that when the review was undertaken it included
the clinical rationale from the GP Practice. As part of their clinical review, the clinical
reviewer requested further information from the practice which included specific
records and transcripts. This was provided and the clinical review was completed.
In response to a request from the complainant seeking further clarification on
comments attributed to the clinical reviewer in the complaint response, a further
clinical review was provided. Whilst this provided further clarification in relation to
comments made, it did not represent a change in clinical view.
2. That the GP Practice was not made aware of the concerns raised by the
clinical reviewer until the inquest process had disclosed these concerns.
You raised that it was unclear how the NHS England Primary Care
Complaints Team ensured that their clinical reviews are fully informed and
how information is shared back to a service/Practice to ensure appropriate
learning can be taken.
Our review has shown it appears that copies of the complaint responses were not
shared with the GP practice. NHS England apologises for this and for any distress
caused to the family. NHS England updated its complaints policy in October 2021,
to state that all responses must be shared with the provider and this change should
have been acknowledged and acted upon. We will ensure all regions are reminded
of the complaints policy and the need to be compliant with the policy.
3. That it was not clear on the general process for cascading information to a
Primary Care Network where it is appropriate to raise awareness of an issue
or condition.
It is not NHS England policy to routinely share information with Primary Care
Networks, however, agreed ways of working and processes are in place to ensure
sharing and learning from complaints.
Regionally, this is carried out through the quality processes in locality teams and
Integrated Care Boards (ICBs) to ensure that any learning is shared, and that GP
Practices are appropriately supported.
Nationally, cascading of information and the dissemination of learning is
implemented through something called the National Learning Report. NHS
England will include a reference to your Report to Prevent Future Deaths in the
next National Learning Report and ensure the learning around the handling of
complaints is included.
Regarding the above, NHS England will be taking the following actions to
address the concerns raised in your Report:
1. NHS England will ensure that all regional complaints teams are reminded of
the requirement to share a copy of its final response with the provider(s)
concerned, in line with NHS England policy.
2. NHSE can confirm that we will include a reference to your Report and the
concerns raised in the next National Learning Report and ensure the learning
around the handling of complaints is included.
3. NHS England will remind all regional complaints teams that it is good practice
to liaise with a coroner when an inquest is running parallel to a complaint.
I would also like to provide further assurances on national NHSE work taking place
around the Reports to Prevent Future Deaths. All reports received are discussed by
the Regulation 28 Working Group, comprising Regional Medical Directors, and other
clinical and quality colleagues from across the regions. This ensures that key learnings
and insights around preventable deaths are shared across the NHS at both a national
and regional level and helps us pay close attention to any emerging trends that may
require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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