Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0532, written 19 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2023 |
|---|---|
| Reference | 2023-0532 |
| Deceased | Margaret Waylett |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| 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.
MISS N PERSAUD HIS MAJESTY’S CORONER EAST LONDON Coroner's Court, 124 Queens Road Walthamstow, E17 8QP REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive Officer, Barts Health NHS Foundation 1. Trust 1 CORONER I am Nadia Persaud, Area Coroner for the coroner area of East London 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 4 November 2022 I commenced an investigation into the death of Margaret Ann Waylett age 78. The investigation concluded at the end of the inquest on the 15 December 2023. The conclusion was a narrative conclusion: Mrs Waylett died as a result of acute cardiac failure following a necessary surgical procedure. Post operative care was not provided in accordance with clear policies and expected standards of practice. Her death was contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH Mrs Waylett suffered a humerus fracture in early October 2022. She consulted with orthopaedic surgeons and it was decided that surgery would be appropriate to maintain her levels of independence. She underwent surgery on the 13 October 2022 and the 1 orthopaedic outcome was satisfactory. Post-operatively, Mrs Waylett's recovery was complicated by ongoing low blood pressure and intermittent oxygen requirements. From the early hours of 17 October 2022, she required a medical assessment, with medical intervention to address a likely pulmonary oedema and likely urinary tract infection. She did not receive the necessary medical intervention and on the 19 October 2022, she suffered a cardiac arrest on the ward. Resuscitation was provided and she was admitted to the intensive care unit. Sadly, she did not recover and she passed away at Whipps Cross Hospital in the early hours of the 20 October 2022. Had Mrs Waylett received the necessary medical intervention from the 17 October 2022 or even on the morning of the 19 October 2022, it is likely that her death would have been avoided. 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 as follows: (1) The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”. (2) The inquest heard that the NEWS charts were not available on the ward rounds. The consultants did not therefore review the charts and were unaware of the frequently raised NEWS scores. The inquest heard that laptops on the ward were unwieldy and time consuming. There were no iPads or vital packs available for the ward round team to easily access the NEWS scores. (3) The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs. Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review. 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 13 February 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, to the family of Margaret Waylett, to the Care Quality Commission, and the local Director of Public Health 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 other person who I believe may find it useful or of interest. 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. 9 19 December 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.
Trust Headquarters Executive Offices Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Date: 16 February 2024 Private & Confidential East London Coroners Court Queens Road Walthamstow London E17 8QP Dear Ms Persaud, Thank you for your letter dated 15 December 2023 following the inquest of Mrs Margaret Ann Waylett, detailing concerns arising from the evidence presented and inviting the Trust to consider the implementation of changes to reduce the risk of future harm or death. The Prevention of Future Death (PFD) report has been reviewed at the Whipps Cross Hospital Board and Divisional Boards to agree actions that will have an impact across the Barts Health group. Your concerns and our response 1. Concern: The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”. Response • Staffing levels have been reviewed by the senior doctors in the divisions of medicine and surgery and are felt to be appropriate. Incidents are reviewed and feedback is listened to from junior doctors and taken into account when deciding on future staffing levels. • Notwithstanding this, on occasions there are staffing gaps which can stretch the resource more than is intended. These risks are always mitigated as well as is possible and are regularly reviewed. Furthermore, plans to expand the Orthogeriatric service are under consideration by the hospital with a vision to provide Orthogeriatric cover for all frailty fractures • A new process has been introduced, in which contact information for on call doctors is displayed in relevant clinical areas so that there is complete clarity about who should be contacted. 2. Concern: The inquest heard that the NEWS charts were not available on the ward rounds. The consultants did not therefore review the charts and were unaware of the frequently raised NEWS scores. The inquest heard that laptops on the ward were unwieldy and time consuming. There were no iPads or vital packs available for the ward round team to easily access the NEWS scores. Response • The senior medical leadership team in the hospital have made it clear to all doctors in the service that regular review of NEWS data is part of professional standards. A review has confirmed that there is enough access to ensure that this happens in each clinical area. • The above has been supported by laptop and iPad device availability which has been increased, with devices having been tested and confirmed as compatible with Cerner and functional for use. Computers on wheels are also available for use. 3. Concern: The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs. Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review. Response • The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed. Junior doctors in both teams have clear and defined roles and responsibilities designed to ensure patients get the attention that is needed. Any patient under the care of the Orthopaedic team for who there is a clinical concern is escalated to either the On call medical team or the Critical Care Outreach team and intensive care for support and further management. Key actions in relation to the above are complete and evidence of completion will be presented at the Whipps Cross Quality and Safety Committee and to the Trust Quality Assurance Committee. The Trust deeply regret that the serious incident investigation report and associated action plan did not provide HM Coroner and the patient’s family with sufficient assurance around the actions implemented. Arrangements will be made to share this letter with the patient’s family and an offer extended to them to meet with senior clinicians to discuss any questions, concerns or additional learning and improvement that the Trust should implement in light of the death Mrs Margaret Ann Waylett. If you have any queries, please do not hesitate to contact me. Yours sincerely Group Deputy Chief Medical Officer On behalf of Group Chief Medical Officer Barts Health NHS Trust
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