Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0394, written 20 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Oct 2023 |
|---|---|
| Reference | 2023-0394 |
| Deceased | Kirsty Hendry |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England 1 CORONER I am Alison Mutch, HM Senior Coroner, for the coroner area of South Manchester 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 18th April 2023 I commenced an investigation into the death of Kirsty Michelle Hendry. The investigation concluded on the 8th September 2023 and the conclusion was one of Narrative: Died from the complications of a subarachnoid haemorrhage caused by a burst aneurysm which was not diagnosed until vasospasms had severely compromised her neurological status and she could not be successfully treated. The medical cause of death was 1a) Cerebral Infarction; 1b) Vasospasm; 1c) Spontaneous Subarachnoid Haemorrhage 4 CIRCUMSTANCES OF THE DEATH On 30th March 2023 Kirsty Michelle Hendry was seen at her surgery by an advanced nurse practitioner. She presented with a headache and vomiting which had started two days previously. She was prescribed antibiotics for a suspected infection. It is probable that the symptoms were due to a subarachnoid haemorrhage due to a burst aneurysm. A hospital referral at this point would probably have identified the subarachnoid haemorrhage and allowed preventative treatment to reduce the risk of her developing severe vasospasm. On 2nd April 2023 an ambulance was called as she was feeling unwell. The ambulance crew did not recognise that her behaviour was inconsistent with her usual presentation. She was taken to Tameside General Hospital where there was a prolonged wait to be seen. A CT scan undertaken showed evidence of a subarachnoid haemorrhage that had occurred previously around 28th March 2023. The scan was incorrectly reported as being clear. At Tameside General Hospital her consciousness levels were reduced, and she was agitated. She had probably developed a severe vasospasm from the subarachnoid haemorrhage. Treatment options at this point are extremely limited. An MRI scan on 5th April 2023 showed multi territorial infarctions and significant narrowing of all the intracranial vessels. On the balance of 1 probabilities, the neurological situation was probably irreversible on her admission to Tameside General Hospital. She was transferred to Salford Royal Hospital where attempts to treat her were unsuccessful. She died at Salford Royal Hospital on 11th April 2023. 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. – The inquest heard evidence that early identification of a burst aneurysm is vital if treatment is to be offered at an early enough stage to reduce the risk of death. The inquest was told that particularly in primary care the symptoms are not readily understood and awareness is often low. In Kirsty Hendry’s case she had the key symptoms that are linked to a burst aneurysm. The evidence was that it was important awareness be raised so that all doctors and other health professionals carrying out examinations in a primary care setting should understand the key symptoms /presentation of a burst aneurysm so that appropriate referrals could be made to secondary care and CT scans be undertaken at an early stage when the probable could be easily identified and treatment options were available. 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 15th December 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 namely 1) on behalf of the Family and; 2) Tameside and Glossop Integrated Care NHS Foundation Trust, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Alison Mutch HM Senior Coroner 20.10.2023 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.
Alison Mutch
HM Senior Coroner
South Manchester Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
22 December 2023
Re: Regulation 28 Report to Prevent Future Deaths – Kirsty Michelle Hendry
who died on 11 April 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20
October 2023 concerning the death of Kirsty Michelle Hendry on 11 April 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Kirsty’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Kirsty’s care
have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused to Kirsty’s family or friends. I realise that
responses to Coroner Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones and appreciate
this will have been an incredibly difficult time for them.
In your Report you raised the concern over the awareness of the symptoms of a burst
aneurysm within primary care health settings. Senior colleagues from NHS England’s
Primary Care, Nursing and Neurology Teams were therefore asked to review your
Report and have input into this response.
All healthcare professionals, including those within Primary Care, have access to and
should be guided by National Institute for Health and Care Excellence (NICE) clinical
guidance. In November 2022, NICE published clinical guidance NG228 on
Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and
management. The clinical guidance provides information on the diagnosis and
management of aneurysm and highlights the importance of urgent investigation and
the need to have a ‘high index of suspicion’ for subarachnoid haemorrhage in people
who present with unexplained acute severe headache. If there is a suspicion of
subarachnoid haemorrhage in people being seen outside of acute hospital settings,
the guidance is to refer them to an emergency department immediately for further
assessment.
Separate NICE clinical guidance, CG150, Headaches in over 12s: diagnosis and
management also makes clear the need for urgent assessment of sudden severe
headaches.
As part of their appraisal and validation, all healthcare professionals working within
Primary Care will undertake Continuing Personal Development (CPD) to keep their
clinical skills up to date. This will include ensuring awareness of up-to-date clinical
guidance.
My nursing colleagues for Primary Care will also be considering Kirsty’s case further,
to include raising awareness of brain aneurysm symptoms among primary care
nursing professionals. They will be keeping my team updated on their agreed next
steps.
NHS England has also engaged with Tameside and Glossop Integrated Care NHS
Foundation Trust regarding your Report and the circumstances surrounding Kirsty’s
care. At the time, there were delays within the Emergency Department to patients
being seen and assessed by doctors. A programme of work is underway both locally
and nationally to address waiting times and delays within Urgent Emergency Care
(UEC). For more information on this, please see the Delivery plan for recovering urgent
and emergency care services which NHS England published in January 2023. The
plan includes an ambition to improve to 76% of patients being admitted, transferred or
discharged within four hours by March 2024.
Following Kirsty’s death, the Trust has developed an action plan which includes further
education for staff on the completion and escalation of neurological observations. They
have also advised that they have acted around the erroneous reporting of Kirsty’s CT
scan, with the third-party provider now having to provide quarterly reports to the Trust,
incorporating a peer review audit. I would refer you to the Trust for further information
on their action plan.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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