Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0230, written 6 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jul 2023 |
|---|---|
| Reference | 2023-0230 |
| Deceased | Gordon Renfrew |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Derby and Burton NHS Foundation Trust · Nottingham 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Executive, Nottingham University Hospitals NHS Trust
1
CORONER
I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire
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 the 14th June 2022, I commenced an investigation into the death of Gordon Harry
Renfrew. The investigation concluded at the end of the inquest on the 28th June 2023
The conclusion of the inquest was a Narrative as follows:
Gordon Renfrew died on the 14th June 2022 at Queens Medical Centre Nottingham, from
extensive cerebral oedema with mass effect leading to brain herniation. This was caused
by a large cerebral infarction, occurring early morning on the 7th June 2022, and involving
the anterior, middle and posterior lobes of the left cerebral hemisphere.
The infarction was caused by a large occlusion in the left internal carotid artery in the
neck, extending to the bifurcation of the internal carotid artery into the anterior and middle
cerebral arteries. The occlusion was caused by arterial dissection and clot/thrombus at
this site, likely caused by a combination of weakness in the arterial vessel wall from
Fibromuscular Dysplasia, and a neck hyperextension injury sustained when diving from a
high board on the 31st May 2022
A Mechanical Thrombectomy was undertaken on the 7th June 22, to try and remove the
clot. This was partially successful, but there remained occlusion of the middle cerebral
artery, with subsequent additional re-occlusion of the internal carotid artery post
procedure.
A Decompression Craniectomy was undertaken on the 10th June 2022, to try and reduce
the effect of the severe cerebral oedema, caused by the large infarct
The NICE guidance on Decompression Craniectomy after stroke, was not followed. There
should have been detailed, early and repeated discussion with the family as to timing of
the Decompression Craniectomy, on the 8th and 9th June 2022. Had this occurred it is very
likely that the procedure would have been performed at an earlier time, although it is not
possible to say, on a balance of probability, that this would have led to Gordon surviving
what was a very severe and extensive stroke.
4
CIRCUMSTANCES OF THE DEATH
Gordon died on the 14th June 2022, at Queens Medical Centre (QMC), Nottingham,
after a short admission. He had been transferred to QMC, from the Royal Derby Hospital
for further management of a severe and extensive stroke. Detailed findings as to how he
came by his death are described within a written Determination dated 28.6.23,
appended to this report
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 –
There is limited evidence to date of improved communication, and a stronger
working relationship, between the stroke team and the neurosurgical team at the
Trust
There is limited evidence to date of the Stroke team having a clear
understanding of the NICE guidance regarding Decompression Craniectomy,
specifically the importance of detailed careful monitoring post stroke, with clarity
about referral criteria to Neurosurgery. The planned Standard Operating
Procedure, which may set out this clarity is not yet finalised.
There are currently limited opportunities for joint case discussion and learning
between the Stroke and Neurosurgical teams. The Interventional
Neuroradiologists could of course also usefully participate in such Educational
opportunities - I note it was
Neuroradiology) rather than the Stroke team, who asked that Gordon was
reviewed by the Neurosurgical team on the early evening of the 7th June 2022
, (Consultant in Interventional
I am not reassured that necessary actions to address these serious issues identified are
in place.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I believe 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 the 31st August 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:
1. Gordons family- His partner
, and his parents
2. The University Hospitals of Derby and Burton NHS Foundation Trust
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
6the July 2023
Dr E A Didcock
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.
30 August 2023 Dr Elizabeth Didcock HM Assistant Coroner for Nottingham City and Nottinghamshire HM Coroner’s Court The Council House Market Square Nottingham NG1 2DT Dear Dr Didcock Medical Director’s Office 3rd Floor, Trust Headquarters City Hospital Campus Hucknall Road Nottingham NG5 1PB www.nuh.nhs.uk Inquest: Gordon Renfrew - Prevention of Future Death Report [PFDR] Response I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Death Notice issued on 6 July 2023 following the sad death of Mr Gordon Renfrew. May I begin with offering my sincerest condolences to Mr Renfrew’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Gordon Renfrew. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Stroke, Neurosurgery and Interventional Radiology service. The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight - Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust. Yours sincerely Medical Director [NUH] Concerns identified through the PFDR Response to the concerns identified through the PFDR There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust The Trust held a Joint PFD response meeting 7.8.23 chaired by MDT attendees included stroke, neurosurgical and mechanical thrombectomy (MT) operational and governance leads. Divisional representation included medical and nursing colleagues and members of the Patient Safety Team. The agenda focused on conducting a pathway review from point of referral to intervention and aftercare. Following this meeting, key principles were agreed: On call stroke consultant to be informed and responsible for all admissions, including tertiary referrals made directly to the Mechanical Thrombectomy team. On call stroke team and Mechanical Thrombectomy team to be electronically informed of patient admissions. The Mechanical Thrombectomy team will be responsible for the patient during the procedure including confirmation of complete informed consent. Post procedure, the responsible stroke consultant is to provide ongoing care including monitoring and onward referral in the event of complications. In the event of the Mechanical Thrombectomy team considering a direct neurosurgical referral, the responsible stroke consultant will also be informed. The pathways will continue to be monitored at the monthly meeting of the Mechanical Thrombectomy Steering Group chaired by the Deputy Medical Director. (Head of Service The Trust also held an Inter-speciality meeting on 24.7.2023 chaired by Neurosurgery) and attended by stroke and neurosurgery heads of service, governance and pathway leads. (Document 1) During this meeting the following issues were discussed; Affirmation of method of referral of stroke patients to Neurosurgery for decompressive craniectomy in relation to NICE criteria. Consensus on how to manage medical issues around stroke management, stroke care in neurosurgery/ITU. Stroke service will have oversight for local patients and those referred as part of tertiary service provision. Consensus on post-operative use of anti-platelet agents and enoxaparin. This included the evidence and risk benefit of starting venous thromboembolism (VTE) prophylaxis and use of aspirin. Early cranioplasty patient selection following craniectomy There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure which may set out this clarity is not yet finalised. The NICE guidance has been re-emphasised with all teams across the pathway and is now incorporated into the SOP. This was discussed during the inter-speciality meeting on 24.7.2023. It was agreed that the NICE guidance is to be incorporated into the cross-departmental SOP. This has now been finalised and due for circulation and to take effect from 1.9.2023. (Document 2). Patients undergoing Decompressive Hemicraniectomy will be monitored neurosurgery governance pathways and will report to the Mechanical Thrombectomy Steering Group. through stroke and The Stroke Department also held a teaching session on Decompressive Hemicraniectomy for ischaemic stroke on 3.7.2023. This session included indications, process of referral and post-procedure care. It was attended by consultants, trainees as well as advanced care practitioners. The department have also introduced specific teaching at induction around decompressive surgery. Nursing teaching sessions have been organised with the stroke teaching practitioner. A presentation was also made to new registrars in early August and has been uploaded to the Trust’s intranet. This includes details around decompressive surgery. (Document 3) A simulated session (SIM session) on how to manage a malignant MCA stroke scenario for medical registrars was delivered on 24.8.2023 by one of the stroke consultants. There are currently limited opportunities for joint discussion and learning between the Stroke and Neurosurgical teams. The Interventional Neuro-radiologists could of course also usefully participate in such Educational activities. It was agreed at the joint PFD response meeting on 7.8.2023 to develop joint learning strategies between the Stroke, Neurosurgical and Neuro-Radiology teams. In addition, all cases of decompressive surgery are to be presented and discussed at the quarterly regional stroke meeting with representatives from stroke and MT services throughout the region. Cases involving both specialities will continue to be discussed at service M & M meetings and relevant colleagues from other specialities involved in the delivery of care will be invited to the meeting. Cross speciality attendance may not always be feasible but regardless, the minutes of individual speciality meetings are to be shared across specialties and actions should be discussed with governance and service leads. This is to be implemented across the Trust. In cases that trigger a SJCR and pathways of care that cross specialties, services should co-ordinate their response through their governance leads and agree around actions, learning and duty of candour. This is to be implemented across the Trust. Complex Mechanical Thrombectomy cases will continue to be presented at and discussed at the Mechanical Thrombectomy steering group with identified learning to be disseminated through Mechanical Thrombectomy pathway leads from radiology, stroke and neuro-interventionists. Summary The actions set out above are intended to address the matters of concern identified in the Prevention of Future Deaths report to ensure that there is a stronger working relationship between the stroke and neurosurgical teams. I hope this response provides both you and the family of Mr Renfrew our commitment to learning from this case to significantly enhance the care for our patients.
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