Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0194, written 4 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 May 2023 |
|---|---|
| Reference | 2023-0194 |
| Deceased | Helen Coogan |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report
Helen COOGAN (died 18.10.22)
THIS REPORT IS BEING SENT TO:
1.
Ritchie Street Group Practice
34 Ritchie Street
London N1 0DG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 27 October 2022, I commenced an investigation into the death of
Helen Coogan aged 77 years. The investigation concluded at the end of
the inquest earlier today. I made a determination at inquest as follows.
“Helen Coogan died in October 2022 from a natural cause, being cancer.
She first sought advice from her general practitioner regarding related
symptoms in July 2022, but there was no result from the qFIT (faecal
immunochemical test) ordered.”
4
CIRCUMSTANCES OF THE DEATH
The medical cause of death was:
1a sudden cardiac death
1b metastatic neuroendocrine carcinoma of the ileocaecal valve and
coronary artery atheroma
1
2 chronic obstructive pulmonary disease, hypertension and
atrial fibrillation
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.
You provided a statement regarding the care given to Ms Coogan by you
and your colleagues at the Ritchie Street Group Practice. In it, you said
that she reported to Dr
in July 2022 that she had had abdominal
cramps present for months, with alternating loose stool and constipation.
You said that a qFIT tool test for blood was requested but there was no
subsequent result. You said the same about the qFIT requested on 13
September 2022.
It was not clear to me why there were no qFIT results but, given the cause
of Ms Coogan’s death, that seems to me to be a matter worthy of your
investigation, particularly in case there is some system issue.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 3 July 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 following.
•
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, children of Helen Coogan
2
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
DATE SIGNED BY SENIOR CORONER
04.05.23 ME Hassell
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.
Partners:
Management Team:
Ritchie Street Group Practice
34 Ritchie Street
London, N1 0DG
Dear Coroner
12-Jun-2023
Re: Mrs Helen Coogan (D.O.B 21-Mar-1945 )
21A Arundel Square
London
N7 8AS
Many thanks for your Prevention of Future Deaths report.
She first presented with bowel symptoms in July 2022. A qFIT test was organised then and in
total organised 4 times between July and Sept 2022 when she had contact with someone and
was noted to have not completed the test. I am unclear why she did not do it.
She did do 3 other stool tests in July 22 but none were for qFIT - she was subsequently advised
of this and the need to do it but still didn’t.
She was reviewed by several GPs and during this period she was also assessed by our
paramedic and the Whittington’s Rapid Response Team. She also attended A&E but took her
own discharge before being assessed. The Rapid Response Team felt she had capacity.
Plan
- discussed it at a partners meeting – nil further could be added
-
raised a significant event to discuss with the wider team to see if anything can
learned and improved from this – nil further could be added.
I cannot see what else could have been done to get a patient do a test that was advised and
organised several times. It is a test patients have to produce and collect a sample to be able to
process.
Private & Confidential.
Ritchie Street Group Practice, 34 Ritchie Street, London, N1 0DG
Yours sincerely
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