Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0465, written 23 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Nov 2023 |
|---|---|
| Reference | 2023-0465 |
| Deceased | Charlotte Burton |
| Coroner | Samantha Goward |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Hospital Death (Clinical Procedures and medical management) 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 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Royal College of Physicians 2. Department of Health 3. NHS England 1 CORONER I am Samantha Goward, Assistant Coroner for the coroner area of Cambridgeshire and Peterborough. 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. Coroners and Justice Act 2009 (legislation.gov.uk) The Coroners (Investigations) Regulations 2013 (legislation.gov.uk) 3 INVESTIGATION and INQUEST On 7 October 2021 an inquest in to the death of Charlotte Burton was opened. Charlotte died on 28 November 2020. The investigation concluded at the end of the inquest on 15 November 2023. The conclusion of the inquest was: Medical Cause of Death: 1a. Acute left ventricular failure 2. Morbid obesity and pre-eclampsia associated with cardiomyopathy Conclusion – Died from a naturally occurring condition, the treatment for which did not commence in time to avoid death. 4 CIRCUMSTANCES OF THE DEATH 1. Charlotte Burton was aged 40 when she became pregnant with her second child. She had a BMI of 45 and was using methadone as part of her treatment plan. As a result, she was under regular surveillance during her pregnancy and had regular growth scans as her age, BMI and methadone use all placed her in the high-risk category. 2. While some concerns were raised regarding care during pregnancy, labour and immediately after delivery, which were investigated by the HSIB and reviewed by an independent expert Obstetrician, none of these were causative of Charlotte’s death. 3. Charlotte returned to hospital on 27 November 2020. While speaking to a neonatal nurse, she was increasingly short of breath, she coughed up blood and was transferred to the emergency department. 4. In considering the care provided to Charlotte at this stage, expert evidence in the fields of Obstetrics, Intensive Care Medicine & Anaesthesia and Cardiology. 5. Based on the expert evidence it was found that from the time Charlotte arrived in the ED, she had a number of signs and symptoms which pointed towards a likely respiratory and/or cardiac pathology which included shortness of breath, coughing up blood, fast respiratory rate requiring supplemental oxygen, bilateral lung crepitations and hypertension. 6. The initial medical review was reasonably comprehensive and the differential diagnosis and management plan appropriate, and appropriate blood tests and investigations were requested. The junior doctor quite appropriately included cardiomyopathy in the differential diagnosis. 7. Charlotte was given Frusemide due to concerns about heart failure and pulmonary oedema. As heart failure was being considered, the high blood pressure should also have been addressed. Expert evidence was that Frusemide should have been given twice a day, so a further dose should have been given around 1900 hours. 8. Charlotte had a raised NT-proBNP level and this is a test for heart failure, but can also be raised with pre-eclampsia. A chest x-ray was said to be difficult to interpret, but did have signs of significant pulmonary oedema. 9. A history of Charlotte having to sit on the side of her bed to catch her breath when she got up in the morning, was also said to be consistent with signs of heart failure. 10. Witness evidence from two of the Consultants (in Obstetric Anaesthesia and Nephrology) who reviewed Charlotte was that there had been some consideration of cardiac issues, which is supported by the medication prescribed, the undertaking of an echo and a decision to transfer to the coronary care team. However, neither was aware of whether or not there had been a review by a Cardiologist and the Trust’s representative checked the records and confirmed that the echo was performed by a suitably qualified technician, but that there had been no cardiology input. 11. The expert Cardiologist was of the view that the treating Consultants had been falsely reassured by the echo showing a preserved ejection fracture and that this distracted everyone from understanding that the ventricle was having to work very hard, didn’t relax properly and that the heart was backing up and causing the pulmonary oedema. 12. The expert accepted that it is much more common in older women and that to find it post pregnancy in a woman in her 40s was unusual. She stated that she would not expect them to have a full knowledge, but would expect an understanding that the NT proBNP and pulmonary oedema could be related to heart failure. 13. In light of the findings of the various examinations, the treating team should have considered diastolic heart failure as a likely cause of the pulmonary oedema which should have led to IV frusemide, glyceryl trinitrate (or a suitable alternative), oxygen and treatment of the hypertension. 14. There were operational issues that delayed a transfer to the coronary care team. The inquest also heard evidence from the treating clinicians that the Trust does not have any Cardiology cover, not even on call, after 5pm weekdays or at the weekend. It was stated that this was not an issue unique to this Trust and that there is a nationwide shortage of trained Cardiologists. The Trust does have the option to call Cardiologists at other hospitals, but there is no provision for on site assessment by a Cardiologist out of hours and transfer is often not possible due to severity of illness or the timescales involved. 15. It was found that had the nature of Charlotte’s condition been recognised, she should have been prioritised for a bed on either the coronary care unit or ICU. Had Charlotte been under the care of ICU or specialist cardiac nurses, they may have recognised the need for cardiology input and discussed this with the on call Physicians to consider seeking advice. It was accepted that that this would not have led to a transfer in Charlotte’s case, but on the balance of probabilities would have led to the Cardiologists or ICU clinicians giving the advice that experts recommended for appropriate treatment. 16. Although Charlotte’s condition did improve by around 1745 hours, she remained short of breath on minimal exertion and by 1930 hours was again requiring oxygen. From 2025 hours her respiratory rate and blood pressure were significantly elevated and oxygen saturations were persistently low. There should have been urgent escalation when Charlotte began to deteriorate again by 1930 hours. 17. 18. By the time the deterioration was recognised at 2245 hours, and intubation occurred at 2315 hours, this was sadly too late and was shortly followed by a cardiac arrest. Had the appropriate treatment, under the advice of a cardiology or intensive care specialist commenced between 1900 and 2100 hours, Charlotte would not have died when she did. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN ARE: 1. The evidence indicates that there is a nationwide shortage of suitably trained Cardiologists and that, particularly in District General Hospital setting, this means that out of hours there is no provision for patients presenting with suspected cardiac problems to be assessed in person by a Cardiologist. The system is therefore reliant upon doctors of different specialities or cardiac nurses recognising the condition and the need for contact with specialist at a different Trust. This still does not allow for in person assessment unless there is a transfer which is not always possible due to the severity of the condition or cannot be achieved in a suitable timescale and this represents on ongoing risk of future deaths. 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 18 January 2024. 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) Charlotte’s family (2) North West Anglian 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 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 Dated: 23 November 2023 Ms Samantha Goward HM Assistant Coroner For Cambridgeshire & Peterborough
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.
Samantha Goward
Cambridge & Peterborough Coroner’s Service
Lawrence Court
Princes Street
Huntington
PE29 3PA
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
10 January 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Charlotte Burton who
died on 28 November 2020
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23
November 2023 concerning the death of Charlotte Burton on 28 November 2020. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Charlotte’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Charlotte’s
care have been listened to and reflected upon.
In your Report you raised the concern that there is a nationwide shortage of suitably
trained Cardiologists and that, particularly in District General Hospital settings, this
means that there can be no out of hours provision for patients presenting with
suspected cardiac problems to be assessed in person by a Cardiologist.
In June 2023, NHS England published the NHS Long Term Workforce Plan, setting
out how it will train, retain and reform its workforce across the next fifteen years to
ensure that we are improving access, providing safe and timely urgent and emergency
care and continuing to reduce elective care backlogs. The Plan is underpinned by the
biggest recruitment drive in NHS history.
NHS England, together with the wider health system is also continuing to deliver the
Medical Speciality Distribution programme; the programme was developed in light of
the Facing the Facts, Shaping the Future report, published by the former Health
Education England (now part of NHS England) and NHS England and a joint review
of distribution of postgraduate medical training places. The Programme commenced
in Autumn 2022, initially looking at three specialties, one of which is Cardiology, and
will continue over the next 10-15 years. Work is in progress to ensure that the
distribution of post graduate speciality training is done in a way that:
• Addresses health inequalities and improve fairness for patients across
England.
• Reduces variation of patient outcomes across England.
• Create fairer distribution of training places in remote, rural, and coastal areas
to meet local population needs.
A Webinar took place in November 2023, outlining how the Long-Term Workforce Plan
will shape the distribution of Speciality Training posts going forward as well as
providing programme updates. This can be found here: Distribution of Specialty
Training: Postgraduate Doctors in Training Webinar | Health Education England
(hee.nhs.uk)
Patient safety remains a key driver behind this work programme, being led and
delivered by NHS England and will inform future decision-making The programme
includes a range of specialities, including cardiology and will in future lead to improved
access for patients to specially trained clinicians.
NHS England is also in the process of developing a plan in collaboration with system
partners to support the workforce in delivering interventions that detect and optimally
manage major conditions such as cardiovascular disease. This should be finalised by
March 2024.
In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which
introduced clinical standards regarding the provision of a “truly seven-day NHS” and
requiring acute trusts to provide board assurance compliance. This included a
requirement for all cardiovascular networks to implement the four priority standards of
timely consultant review, improved access to diagnostics, consultant directed
interventions and ongoing review into high dependency areas across all seven days
of the week. There is a good level of compliance with these standards across acute
trusts and many services and surgical and diagnostic lists are operating at weekends
and evenings.
The NHS continues to encourage local health systems to develop effective workforce
planning to ensure that they have the sufficient qualified staff working across their
Trusts and wider system that are required for their population care needs. The NHS
People Promise also helps NHS providers to consider ways to recruit and retain staff.
Work is in progress to ensure that future distribution of training posts to help ensure
the supply of doctors is matched to population need. You will need to refer to
Cambridgeshire and Peterborough Integrated Care Board (ICB) on what system
arrangements they have in place for their cardiology provision and workforce, to
include transfer policy on weekends.
NHS England will also consider carefully responses to your Report from the DHSC
and the Royal College of Physicians and any actions required from us to support
further improvement.
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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