Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0181, written 7 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jun 2023 |
|---|---|
| Reference | 2023-0181 |
| Deceased | David Wood |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Oxford University 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.
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 Chief Executive - John Radcliffe Hospital 2 MK Together Partnership 1 CORONER I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes 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 29 June 2022 I commenced an investigation into the death of David WOOD aged 56. The investigation concluded at the end of the inquest on 06 December 2022. The conclusion of the inquest was that: The deceased having recently undergone open heart surgery in Oxford developed a severe depression. He was found on 22nd June 2022 hanging at his home Milton Keynes. 4 CIRCUMSTANCES OF THE DEATH Mr. Wood had been suffering from depression and difficulty sleeping following his release from hospital after the surgery. He had been to see his doctor about this. On Wednesday the 22nd of June 2022 Mr. Wood was at home with his wife. During the afternoon Mrs. Wood went out leaving him sat in a downstairs chair. On her return he was no longer in the chair and she thought that he had gone upstairs to try and sleep. Later that evening at 8pm she went to wake him up. Mrs Wood found him suspended by the neck. 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) Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance, The protocols for discharge following heart surgery should be reviewed in order to prevent Regulation 28 – After Inquest Document Template Updated 30/07/2021 similar deaths. 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 August 01, 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 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: 07/06/2023 Tom OSBORNE Senior Coroner for Milton Keynes 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.
The John Radcliffe Hospital Headley Way Headington Oxford OX3 9DU 6 July 2023 PRIVATE AND CONFIDENTIAL Mr Tom Osborne HM Senior Coroner for Milton Keynes Dear Mr Osborne Inquest into the death of David Wood Following the tragic death of Mr David Wood, and subsequent inquest on 6 December 2022, I am writing on behalf of Oxford University Hospitals NHS Foundation Trust (OUH) to provide a response to your Regulation 28 Report to Prevent Deaths dated 7 June 2023. The inquest referral from the Milton Keynes Coroner’s Office dated 28 October 2022 indicated that you did not require any formal evidential reports from OUH clinical staff, but you asked that OUH provide a copy of the Structured Judgment Review once completed. As such you did not hear any evidence from OUH clinical staff at the inquest hearing on 6 December 2022. A copy of the Record of Inquest was sent to OUH Legal Services after inquest hearing, but nothing further had been heard from your office until 7 June 2023 when the Regulation 28 Report was sent by email to OUH Legal Services ( ). At section 5 of the Regulation 28 Report to Prevent Future Deaths you have set out your concerns: “Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths”. to educate her as to the possibility of delirium, and to help plan his The OUH Structured Judgment Review dated 17 August 2022 was written as part of the OUH’s Mortality Review Process and disclosed to your Officer prior to the inquest Page 1 of 2 hearing on 6 December 2022. Based on the SJR plus internal management review processes, the Directorate identified four key learning points: 1. Including a section in the Pre-Operative Assessment on previous mental health and substance use in the past medical history section, would represent best practice in highlighting patients with significant psychiatric histories so that appropriate care could be instituted during and after the admission. The POA clerking proforma has been amended accordingly and patients are also given a leaflet explaining the small chance of post-operative delirium, and that it is usually transient. 2. If post-operative delirium occurs, considering involving an appropriate family member in discharge discussions (with the patient’s consent), to alert them to what to expect in the process of recovery and when to seek further medical assistance after discharge. Since the incident, this has been addressed via a full-time discharge coordinator for the heart centre adopting more of an MDT approach. The nursing team have also been educated about the free NHS talking therapies service plus the British Heart Foundation resources online support groups and information. 3. Amendment to consent-form stickers used to list frequent or clinically significant complications after cardiac surgery, which previously did not include delirium. This has been addressed. 4. The liaison process for seeking advice and/or direct clinical input from Psychological Medicine for in-patients should be clarified. The Psychological Medicine Team have indicated that initial contact for both types of referral to their service is via the rostered Consultant-of-the Week, either via phone or bleep. The Divisional Director of MRC Division, which includes Cardiac Surgery, has provided assurance to me that the actions to implement the four learning points have been completed. Yours sincerely Chief Executive Officer Page 2 of 2
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