Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0240, written 15 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 | 15 May 2023 |
|---|---|
| Reference | 2023-0240 |
| Deceased | Roy Walklet |
| Coroner | Duncan Ritchie |
| Coroner area | Stoke on Trent and North Staffordshire |
| 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.
23 June 2023
STRICTLY PRIVATE & CONFIDENTIAL
Mr D Ritchie
H M Assistant Coroner
Stoke on Trent and North Staffordshire
Dear Mr Ritchie
Executive Suite
Trust Headquarters
Springfield
City General Site
Newcastle Road
Stoke on Trent
ST4 6QG
Roy WALKLET
I am pleased to provide a response to your report under paragraph 7 of Schedule 5 of the Coroners and
Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013,
addressing your concerns surrounding the death of Roy Walklet.
Recorded Circumstances of the Death
Roy Walklet died on 9 April 2022 at the Royal Stoke University Hospital, Stoke on Trent of multiorgan
failure caused by a massive gastroduodenal haemorrhage which was contributed to by the taking of
ibuprofen. Mr Walklet had attended hospital on 12 March 2022 complaining of abdominal pain. Gallstones
were identified and these were assumed to be the cause of the abdominal pain. An endoscopy test which
could have been administered to check for an ulcer was not carried out at that stage. Mr Walklet was re-
admitted to hospital on 7 April 2022 suffering from a bleeding duodenal ulcer. Despite attempts to stem
the bleeding he suffered multiple large bleeds which caused his death.
Concerns
During the course of the inquest you felt that evidence revealed matters giving rise for concern and whist
, it was not enough to satisfy
you heard some evidence in relation to these concerns from
you without further clarification. The matters requiring clarification are:
1. There was a failure to carry out an urgent/emergency OGD on 7 April 2022 - the reason given in
evidence was that there was no medical bed available for Mr Walklet at the time (post OGD) – he
should have attended for OGD from ED but the current system prevents patients from going back
to ED and requires a medical bed ‘in waiting’ post procedure – he had the procedure the following
morning.
2. Roy was not seen on the ward round on 8 April 2022 – evidence in this regard was a little unclear
with
believed that Mr Walklet was still in ED on the morning of 8 April 2022; this requires clarification.
advising that the patient was not on his ‘new patient’ list, however, the family
Action Taken
1. The issue of why Mr Walklet did not have his gastroscopy on 7 April 2022 was discussed in the
Gastroenterology Mortality and Morbidity Meeting on 18 May 2022; at that meeting, the Clinical
Lead for Gastroenterology agreed to discuss further with the endoscopy manager to develop a
system that facilitates an ‘in-patient’ bed space for those awaiting urgent or emergency
gastroscopy.
A Standard Operating Procedure has been developed and this essentially sets out a pathway for
patients such as Mr Walklet in that it prioritises in-patient bed spaces for those requiring a hospital
bed following an urgent or emergency gastroscopy. The pathway will be monitored by the bed
management team.
2. A review has been undertaken of Mr Walklet’s care in the Emergency Department and it identifies
that he was transferred to Ward 230 at 11pm on the evening of 7 April 2022. In addition to this, the
review also found that the patient was reviewed in a timely manner whilst in ED and was cared for
appropriately.
did not review Mr Walklet on
I understand that evidence at the inquest heard that
Ward 230 because he has not been added onto the ‘new patient’ ward list.
confirmed
at the inquest that this matter had been rectified and that he would now be aware of all new
patients. A board round is held every morning in Ward 230 with the Consultant of the ward, junior
doctor team, nursing manager/charge nurse, discharge co-ordinator, physiotherapist, pharmacist.
A quick update is made on all patients who are under the Gastroenterology Team in ward 230
before starting the formal ward round. Hence a process has been developed which should
minimise the risk of a patient being missed during the daily morning ward round.
I do hope that the above information provides assurance that the Trust has taken the issues raised
seriously and that in the future, patients who require a bed following urgent gastroscopy will be prioritised
accordingly.
Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly.
Yours sincerely
CHIEF EXECUTIVE
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 Royal Stoke University Hospital 1 CORONER I am Duncan RITCHIE, H M Assistant Coroner for the coroner area of Stoke-on-Trent and North Staffordshire 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 20 April 2022 I commenced an investigation into the death of Roy WALKLET aged 62. The investigation concluded at the end of the inquest on 03 April 2023. The conclusion of the inquest was that: Roy Walklet died on 9th April 2022 at the Royal Stoke University Hospital, Stoke-on-Trent of multiorgan failure caused by a massive gastroduodenal haemorrhage which was contributed to by the taking of ibuprofen. Mr Walklet had attended hospital on 12th March 2022 complaining of abdominal pain. Gallstones were identified and these were assumed to be the cause of the abdominal pain. An endoscopy test which could have been administered to check for an ulcer was not carried out at that stage. Mr Walklet was readmitted to hospital on 7th April 2022 suffering from a bleeding duodenal ulcer. Despite attempts to stem the bleeding he suffered multiple large bleeds which caused his death. 4 CIRCUMSTANCES OF THE DEATH 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) On 7th April 2022 the deceased Mr Walklet attended the Accident and Emergency Department of the Royal Stoke University Hospital suffering from a bleeding duodenal ulcer. A consultant gastroenterologist decided that a gastroscopy should be undertaken that same day to identify and treat the cause of the bleeding. The gastroenterologist felt that it was important for the gastroscopy to be undertaken without delay because there was potential for Mr Walklet to suffer another big bleed, which could be fatal. No gastroscopy took place on 7th April 2022. During the inquest I was told that this was because Mr Walklet had not been allocated a bed in the hospital and a gastroscopy would not take place until a bed had been allocated to him because a patient cannot be returned Regulation 28 – After Inquest Document Template Updated 30/07/2021 to the Accident and Emergency Department from the gastroscopy department. A gastroscopy eventually took place on 8th April 2022. Mr Walklet later suffered further bleeding from the duodenal ulcer which resulted in his death. The delay in undertaking the gastroscopy was not causative of Mr Walklet’s death, but I was told that systems and procedures in the Hospital remain as they were at the time of Mr Walklet’s death – i.e. that a stable patient with a gastric bleed who was being cared for in the Accident and Emergency Department could not have a gastroscopy until a bed for them became available in the Hospital. I was further told during the inquest that Mr Walklet was allocated a bed in the Hospital either late on 7th April 2022 or early on 8th April 2022 and that his care was allocated to a consultant gastroenterologist during his morning ward round but did not do so. aware that Mr Walklet had been allocated to his list of patients. Mr Walklet’s family believe that this error occurred because, whilst Mr Walklet had been allocated a bed on the ward, he actually remained in the Accident and Emergency department. As a result, Mr Walklet’s condition and care was not reviewed by the consultant gastroenterologist until later that day. At the time Mr Walklet was still suffering from a bleeding duodenal ulcer from which he was to die later the same day. should have seen Mr Walklet told me that he was not . 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 June 21, 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: 15/05/2023 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Duncan RITCHIE H M Assistant Coroner for Stoke-on-Trent and North Staffordshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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