Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0130, written 21 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 | 21 Apr 2023 |
|---|---|
| Reference | 2023-0130 |
| Deceased | Peter Lawrence |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
representative at DWF.
, consultant trauma and orthopaedics surgeon via his legal
1
CORONER
I am Mrs Heidi J. Connor, senior coroner for the coroner area of Berkshire.
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
I conducted an inquest into the death of Peter William Frederick Lawrence, which
concluded on 15th March 2023. Mr Lawrence was 79 at the time of his death.
I recorded a short narrative conclusion : complication of necessary surgery.
His cause of death was:
1a Septic Shock
1b Gluteal and Hamstring Abscess
1c Spinal Decompression
2 Type 2 Diabetes Mellitus, Ischaemic Heart Disease, Cerebrovascular Disease
4
CIRCUMSTANCES OF THE DEATH
In brief terms, Mr Peter Lawrence underwent spinal surgery at Spire Hospital in
Portsmouth on the 11th January 2022. He had had several other spinal operations before
then. He developed infection and abscesses, and the evidence showed that the most
likely origin of that infection was the surgery that he had in January. He died at the Royal
Berkshire Hospital on the 3rd March 2022.
As part of the investigation, I reviewed the medical records. These included medical
records from the time of his surgery at Spire Hospital in Portsmouth, but also included
outpatient appointments (as a private patient) with
December 2021 (by telephone), 26th January 2022, and 23rd February 2022.
on (inter alia) 29th
made no formal medical records of the
My investigation revealed that
outpatient appointments. It is right to point out that
and typed up by his secretary (to the patient and his GP), and some of this
correspondence is relatively detailed. It was advanced on his behalf that this
correspondence effectively represents a medical record and it is entirely appropriate to
make ‘records’ in this way.
did send letters dictated
I did not accept that this correspondence is as full as a medical record would be. Much
of the correspondence relates predominantly to plans and proposed courses of action,
rather than a record of the patient’s condition at that time.
accepted that much of the further information which he gave
In questioning,
at the inquest (and referred to in a witness statement) is not recorded anywhere other
than his own personal memory.
Even leaving aside GMC requirements in relation to record-keeping, it is plainly the case
that records are important for patient safety, and storing information about a patient in an
individual doctor’s memory is clearly unacceptable. Leaving aside the issue of protection
for the clinician, this approach carries a risk for patients.
brought to the inquest – both in his oral evidence in court and in his
I was clear at the inquest that I had no reason to disbelieve the additional evidence
which
witness statement – but I am concerned about the risks of this continued approach for
other patients. In questioning,
practising in this way.
clarified that his intention is to continue
Adequate medical records are fundamental to patient safety, particularly when patients
are receiving treatment from numerous clinicians and organisations both in the private
sector and in the NHS.
I did not find that the record-keeping approach in this case contributed to Mr Lawrence’s
death, but I remain concerned of a risk to other patients, in adopting this approach.
5
CORONER’S CONCERNS
The issue about which I have concern is clear.
should review his record-keeping approach, perhaps with the benefit of legal
advice and reference to GMC guidance. An approach of ‘storing’ information in an
individual clinician’s memory carries a risk (including a risk of death) for future patients.
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 16th June 2023.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to Mr Lawrence’s family. I have
also sent a copy to the Spire Hospital in Portsmouth, and to the senior coroner in
Hampshire, given the location of these events.
To be clear, I have included the Spire Hospital in this regulation 28 report, not because I
had concerns about record-keeping within the hospital setting. However, they are
involved in recruiting and relying on private consultants to carry out operations for
patients under their care.
I do not require a formal response from Spire Hospital.
9
21st April 2023
Mrs Heidi J. Connor
Senior Coroner for Berkshire
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