Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0037, 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 | 2023-0037 |
| Deceased | Donald Brown |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Gloucestershire Hospitals NHS Foundation 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.
H M Senior Coroner for Gloucestershire Ms Katy Skerrett REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Gloucestershire Hospitals NHS Foundation Trust, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN 1 CORONER I am Katy Skerrett, His Majesty’s Senior Coroner for Gloucestershire. 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 the 8th March 2021 I commenced an investigation into the death of Donald Charles Brown. The investigation concluded at the end of the inquest on the 13th December 2022. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Aspiration pneumonia, 1B C1/C2 fracture dislocation. 4 CIRCUMSTANCES OF THE DEATH Donald Charles Brown “Donald” was an 87 year old man who suffered a fall at home on the 31st January 2021. He was taken to hospital and underwent CT examination. No fractures were reported. Following further investigations he was discharged home. Following discharge Donald continued to experience neck pain and difficulty swallowing. He was readmitted to hospital on the 26th February 2021 and was treated for aspiration pneumonia. Further CT imaging demonstrated that he had suffered a displaced fracture of the C2 vertebra with spinal cord compression. This injury had been sustained in his fall on the 31st January. It was visible on the CT imaging taken on that day. However it was not reported. It is likely that the severity of this injury led to his swallowing difficulties and caused aspiration pneumonia. Neurosurgical opinion was sought and advised against operative intervention. Donald’s condition thereafter steadily deteriorated and he passed away at 08.15 hours on the 4th March 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 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 significant understaffing of the Radiology department at the hospital. 2. The national shortage of radiology trainee posts. 3. The expectation that the reporting of all scans including non urgent, will be done within an hour. 4. The appointment of call handlers to triage calls to reduce the demands on the radiologists’ time has been delayed due to cost. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk 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 4pm 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 (1) Taynton’s Solicitors representing the family of Donald Brown, (2) National Medical Director, (3) Royal College of Radiologists, 63 Lincoln’s Inn Fields, London WC2 3JW. 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 Dated 31st January 2023 Signature_____ ____________________ Ms K Skerrett His Majesty’s Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | coroner@gloucestershire.gov.uk
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.
Gloucestershire Hospita Is
NHS Foundation Trust
Alexandra House
Cheltenham General Hospital
Cheltenham
Gloucestershire
GL53 ?AN
27 March 2023
Ms K Skerrett
HM Senior Coroner for Gloucestershire
Gloucestershire Coroner's Court
Corinium Avenue
Barnwood
Gloucester
GL4 3DJ
Dear Ms Skerrett
Mr Donald Charles Brown -Inquest 13 December 2022
I am writing in response to your letter dated 31 January 2023 in which you raised concerns arising
from the evidence heard this inquest. It is your view that there is a risk that future deaths will occur
unless action is taken about these concerns.
The matters of concerns are:
1.
2.
3.
4 .
The significant understaffing of the Radiology department at the hospital
The national shortage of radiology tra inee posts
The expectation that the reporting of all scans including non-urgent, will be done within one hour
The appointment of call handlers to triage calls to reduce the demands on the radiologist's time
has been delayed due to cost
The Trust's response is as follows:
1.
The significant understaffing of the radiology department at the hospital
The department has an establishment of 31 whole time equivalent radiologists and
presently has one vacancy, which is filled by a locum consultant. This equates to a vacancy
rate of c3% This compares to a national vacancy rate of 29%. The Trust has an excellent
reputation for training radiologists, coming top in the national survey for trainee experience.
The last four appointments have all been former trainees of the organisation and we are
confident we can continue to maintain a fully established workforce.
Gloucestershire Hospita Is
NHS Foundation Trust
2.
The national shortage of radiology trainee posts
The allocation of trainees is the responsibility of Health Education England. Concerns have been
expressed about the distribution of trainees nationally, reflecting the bias to distribution to
London. HEE
the process of redistributing a proportion of these trainees and
Gloucestershire Hospitals has been successful in securing an additional (eighth) trainee from
the Severn Deanery commencing in post in August 2023. Additionally, we are aiming to create
a fellowship post (post training role) for further applicants.
is in
3.
The expectation that the reporting of all scans including non-urgent. will be done within one hour
The Trust works to the national NHS Seven Day Services Clinical Standards, Version 2,
(8 February 2022) which for inpatients and patients attending the emergency department
reflects the following minimum standards, which the department strives to exceed.
•
•
•
Within one hour for critical patients (scans that immediately alter a patient's management)
Within 12 hours for urgent patients (scans that will alter a patient's management, but not
necessarily on that day)
Within 24 hours for non-urgent patients.
4.
The appointment of call handlers to triage calls to reduce the demands on the radiologist's time
has been delayed due to cost
The service has a number of initiatives in hand to reduce the administrative burden on
radiologists including but not limited to
• Recruitment of three "inpatient navigators" who will undertake call triage amongst other
•
duties.
training our radiographers to 'vet' scans under the radiologist pre-defined protocols, to
further reduce the administrative burden on the radiologists.
• Production of a list of 'Frequently Asked Questions' for radiography staff with the aim of
reduce the need for interruptions to radiology sessions
• We are investigating an Artificial Intelligence tool to facilitate better triage between urgent
and less urgent scans
I have also enclosed a copy of the completed and updated Action Plan.
I hope this information is useful.
Please do not hesitate to contact me if I can be of further assistance.
Yours sincerely
Chief Executive
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