Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0101, written 23 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Mar 2023 |
|---|---|
| Reference | 2023-0101 |
| Deceased | Jade Revell |
| Coroner | Sarah Huntbach |
| Coroner area | Derby and Derbyshire |
| Category | Other 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 TPP LTD 1 CORONER I am SARAH HUNTBACH ASSISTANT CORONER for the coroner area of Derby & Derbyshire 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 05 January 2022 I commenced an investigation into the death of Jade Paula REVELL aged 30. The investigation concluded at the end of the inquest on 22 March 2023. The conclusion of the inquest was that: Jade Revell was taken to Chesterfield Royal Hospital on 25 December 2021 having suffered a sudden cardiac event at home. Despite extensive resuscitation she passed away in hospital the same day. Jade suffered with an eating disorder and was under the care of the mental health team. Prior to making a change to her medication her bloods were tested. On 27 October 2021 the bloods were electronically sent to Jade’s GP practice. These showed a low potassium level which required further action. There was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death. 4 CIRCUMSTANCES OF THE DEATH Jade Revell died from a sudden cardiac event. A missed opportunity to treat hypokalaemia shown in blood results on 27 October 2021 has more than minimally contributed to the cause of the sudden cardiac event. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results. To do so would need the clinician to scroll down and a scroll feature is not available. This gives rise Regulation 28 – After Inquest Document Template Updated 30/07/2021 to the risk of an abnormal result being missed and unactioned. Abnormal (out of range) should be more visable – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 May 17, 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 I have also sent it to ( Miss Jade Revell’s mother) (Miss Jade Revell’s father) – Primary Health Care 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 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 by the Chief Coroner. 9 Dated: 23 March 2023 Sarah Huntbach Assistant Coroner Derby & Derbyshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Sarah Huntbach Assistant Coroner Derby and Derbyshire Coroner’s Court St Katherine’s House St Mary’s Wharf Mansfield Road Derby DE1 3TQ 20th April 2022 Dear Ms Huntbach Re: Regulation 28 report – Jade Paula Revell Thank you for your letter of 23rd March 2023. I have previously been a fulltime NHS GP, and for the last 19 years been the clinical director and principal clinical safety officer for TPP, a company based in Leeds that supplies the SystmOne product for use by GP surgeries. The product has been in continuous usage for 24 years. There is only one version of SystmOne. On 14th September 2022 TPP were contacted by who provided details about this sad and tragic incident. Helpfully he was able to demonstrate to our helpdesk what had happened. I was able to speak to of screenshots from SystmOne, using fictitious data. on 15th September 2022. I will address the issues he raised with the use As a result of our conversation we were able to identify a change to be made in the system and this was released to all our users on the evening of 13th October 2022. If the document does not adequately answer your concerns I would be happy to demonstrate the features on a Teams (or equivalent) call. From our discussion with it appears that the GP had missed an abnormal potassium result when reviewing the results within the patient record. I use the expression ‘within the patient record’ as a pathology result first appears in the ‘Pathology Inbox’ and is processed from that screen. This is where the abnormality is first highlighted. Figure 1 below shows an example of the Pathology Inbox screen. The abnormal potassium result would have made the whole line that included Jade’s name to appear in red, showing that there was an abnormality to be reviewed. A user would have opened this result (example Figure 2) which shows how the results are individually flagged as normal or abnormal. The user would then file the result which includes the opportunity to flag the result as normal / abnormal / etc. This process would have to occur before the result would be available within the record for review. Figure 1 Figure 2 Once the result has been filed there are two ways to review the result in SystmOne. able to show me that one of the methods had created the opportunity for a busy GP to miss the abnormal result. was Figure 3 shows the table layout for reviewing results – where abnormal results are highlighted. There is no issue with this screen. Figure 4 shows the full Pathology and Radiology inbox view that the GP used. Scroll bars are present in the system (contrary to what is detailed in the Regulation 28 Report) whenever the full information cannot be displayed in one screen. The behaviour that the GP clicked on one result (in the middle column) and used the scroll bar in the right column to look at results not visible, the scroll bar did not automatically reset to the top, if the next result was highlighted was that if then selected. A very busy GP might then miss an item at the top if the scroll bar position was at the bottom of the page. Figure 3 Figure 4 The change to ensure that the scroll bar reset to the top of the page was made and released to all our users 4 weeks later. Conclusion I am grateful to timely manner. for contacting us directly so that we could take appropriate action in a In general I would expect abnormal results such as this to be acted upon at the pathology filing stage, and we recommend that clinicians use the view in figure 3 (rather than figure 4) to highlight the trends in blood results. Please let me know if you have further concerns. Yours sincerely
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