Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0120, written 18 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Apr 2023 |
|---|---|
| Reference | 2023-0120 |
| Deceased | John Stiff |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barking, Havering and Redbridge University Hospitals NHS 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.
MISS N PERSAUD HIS MAJESTY’S CORONER EAST LONDON Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care 2. CEO Barking, Havering and Redbridge University Hospitals NHS Trust 1 CORONER I am Nadia Persaud, Area Coroner for the coroner area of East London 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST 1 On 1 December 2022 I commenced an investigation into the death of John Edward Stiff. The investigation concluded at the end of the inquest on the 5 April 2023. The conclusion of the inquest was that Mr Stiff died as a result of an accident (following a fall). 4 CIRCUMSTANCES OF THE DEATH On the 10 November 2022, Mr. Stiff was admitted to Queen's Hospital having suffered a believed unwitnessed fall. In Queen's Hospital, he was diagnosed as suffering from an undisplaced fracture of the pelvis. A decision was taken to treat Mr. Stiff conservatively. Even though there was no surgical intervention, he was admitted under the care of the orthopaedic team. The orthopaedic team are not specialists in controlling medical problems associated with fractures. During the course of the admission, Mr. Stiff's appetite was much reduced. He was not offered any nutritional supplements. On the 15 November 2022 he had reduced oxygen saturations and the medical team became involved in his care. He was diagnosed as suffering from a chest infection. He was treated with supplemental oxygen; intravenous fluids and intravenous antibiotics. Sadly, Mr. Stiff did not recover and he passed away at Queen's Hospital on the 16 November 2022. It is likely that the fall and fractured pelvis on the 10 November 2022 caused a decline in health and mobility which would have contributed to the development of the fatal pneumonia. 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: The Inquest heard evidence from an orthopaedic surgeon that patients such as Mr Stiff, who suffer hip and pelvic fractures and who have a number of additional age-related co-morbidities, would be best cared for by ortho- geriatricians. The inquest heard that this matter has been raised by the orthopaedic team on multiple occasions, but the orthogeriatric provision has not been increased. The Inquest also heard that the lack of orthogeriatric provision is a national issue of concern within the NHS. Orthopaedic trauma in elderly patients often exacerbates underlying medical conditions. Orthogeriatric trained staff would be better trained to recognise and treat medical co-morbidities. It is therefore considered that improved access to orthogeriatric care for this patient cohort could prevent future untimely deaths. 2 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 13 June 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 to the Inquest, family of Mr Stiff, to the Care Quality Commission and to the local Director of Public Health 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 18 April 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.
From Andrew Stephenson MP Minister of State for Health and Secondary Care 39 Victoria Street London SW1H 0EU Miss N Persaud His Majesty’s Coroner - East London Walthamstow Coroner's Court, Queens Road Walthamstow, London E17 8QP Dear Miss Persaud, 9 May 2024 Thank you for your Regulation 28 report to prevent future deaths dated 18 April 2023 about the death of John Edward Stiff. I am replying as Minister with responsibility for heath and secondary care. Firstly, I would like to say how saddened I was to read of the circumstances of John Edward Stiff. I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter. The report raises concerns over orthogeriatric provision both at the Barking, Havering and Redbridge University Hospitals NHS Trust and nationally. Orthogeriatric care is a medical-surgical model which brings together multidisciplinary health professionals from trauma, orthopaedics and geriatric medicine to treat the fracture and frailty issues affecting people with hip fractures. I understand that Orthogeriaric provision varies across the NHS. Each individual Trust will create their own care pathways, having regard to both their patients and the skills of their workforce. The NHS Long Term Workforce Plan (LTWP) published by NHS England on 30 June last year sets out the case for reforming medical education and training and states that “To care for ever increasing numbers of older people with multiple and complex conditions, health and care professionals will need to continue to enhance their specialist knowledge while also 1 maintaining and developing their generalist and core skills. This will support health and care professionals to work in multidisciplinary, integrated teams that respond to population health needs and effectively deliver care in communities. The way we train staff also needs to address predicted future workforce shortfalls, match differing generational expectations and meet the needs of those joining the workforce in future.” The LTWP also sets out an aim to double the number of medical school places in England to 15,000 places a year by 2031/32, and to work towards this expansion by increasing places by a third, to 10,000 a year, by 2028/29. We have brought forward the trajectory of this planned expansion for the last 2 years, having allocated 205 and 350 additional places for the 2024 and 2025 academic years respectively. This expansion builds on a recent increase in Government funded medical school places. This previous increase was completed in September 2020 and delivered five new medical schools in England, and an additional 1,500 medical school places per year for domestic students in England. This represented a 25% increase and took the total number of medical school places in England to 7,500 each year. These expansions and reforms will increase the pool from which future Geriatricians, Orthopaedic surgeons and other specialists can be drawn, and increase the skills in the medical workforce that are required to treat complex patients. Together this will facilitate more staff becoming involved in Orthogeriatric Care. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE
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