Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0053, written 1 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Feb 2024 |
|---|---|
| Reference | 2024-0053 |
| Deceased | Peter Stajic |
| Coroner | Crispin Oliver |
| Coroner area | West Yorkshire Western |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | Bradford Teaching Hospitals 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Yorkshire Ambulance Service 1 CORONER I am Crispin OLIVER, HM Assistant Coroner for the coroner area of West Yorkshire Western Coroner Area 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 21 March 2022 I commenced an investigation into the death of Peter STAJIC aged 60. The investigation concluded at the end of the inquest on 01 February 2024. The conclusion of the inquest was that: He died from a complication following a medical procedure to which a missed opportunity to provide medical intervention contributed. 4 CIRCUMSTANCES OF THE DEATH Peter was pronounced dead at 04.50 on 27 February 2022 at Calderdale Royal Hospital, Halifax. He was aged 60, fit and well save that he had required a carotid endarterectomy - undertaken on 12 January 2022. Due to a post operative haematoma, he was discharged on 16 January 2022. He developed an infection at the suture site. He was prescribed antibiotics by his GP. On 25 February he attended the Emergency Department at Calderdale Royal Hospital. This was an opportunity to discuss his case with a vascular consultant. It did not happen. On 26 February paramedics attended Peter at home at 10.42. There was evidence available of a herald bleed indicating that a major haemorrhage was likely to happen. This was not appreciated at the time and an opportunity was missed to admit Peter to the specialist Vascular Unit at the Bradford Royal Infirmary where, on the balance of probability, a procedure necessary to save his life could have been undertaken. In fact Peter was admitted to Calderdale Royal Hospital Emergency Department following a second attendance on his at home at 20.32 on 26 February. The concern at that stage was in relation sepsis, not the risk of haemorrhage. He was triaged to level 3. At 22.56 a nurse noted bleeding at the suture site. She reported this to a consultant of the Department, who was not equipped to appreciate its significance. Its is not available to conclude on a balance of probability that at that stage there would have been sufficient time to intervene to save Peter's life. Peter suffered a catastrophic haemorrhage shortly after 01.05 and consequently died. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Although detailed expertise concerning a herald bleed is specialist vascular knowledge that the paramedics who attended Peter at his home on the morning of 26 February 2022 would not be expected to possess, the evidence to the Inquest was that they would not have had any training in identifying one, nor any protocol for them to follow. 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 March 28, 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 I have also sent it to Bradford Teaching Hospitals NHS Foundation Trust Calderdale Royal Hospital Mortuary 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: 01/02/2024 Crispin OLIVER HM Assistant Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Association of Ambulance Chief Executives 25 Farringdon Street London EC4A 4AB T: 020 7118 0977 E: 29 April 2024 BY EMAIL: Crispin Oliver HM Assistant Coroner West Yorkshire Western coroner area Dear Mr Oliver PETER STAJIC (DECEASED) I am writing in response to the preventing future deaths report received at the Association of Ambulance Chief Executives and I respond as our Director of Operational Development and Quality Improvement on behalf of AACE. On behalf of AACE, I would like to extend our sincere condolences to the family of Peter Stajic. It may be helpful for us to explain that AACE is a private company owned by the English and Welsh NHS ambulance services. Its purpose is to support its members, UK NHS ambulance services, in the implementation of national agreed policy and to act as an interface, where appropriate at a national level, between them and their stakeholders. It is a company owned by NHS organisations and possesses the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance chief executives and chairs along with a network of national specialist sub-groups. We respond in relation to your matter of concern: Although detailed expertise concerning a herald bleed is specialist vascular knowledge that the paramedics who attended Peter at his home on the morning of 26th February 2022 would not be expected to possess, the evidence to the inquest was they would not have had any training in identifying one, nor any protocol for them to follow. Firstly it is important to note that the JRCALC guidelines are advisory and have been developed to assist healthcare professionals inform patients and to make decisions about the management of the patient’s health, including treatments. This advice is intended to support the decision making process and is not a substitute for sound clinical judgement. The guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore, individuals using these guidelines must personally ensure they have the appropriate knowledge and skills to enable suitable interpretation. All our JRCALC guidance is updated on a regular basis. The guidance is available to all UK ambulance paramedics and is used on an App. We often respond to incidents and issues raised so that we can improve the guidance towards improving patient care. We currently have specific JRCALC guidance for vascular emergencies and this details conditions such as aortic aneurysm, aortic dissection, ischaemic limbs, AV fistula bleeds and diabetic foot problem. We discussed your matter of concern at our JRCALC meeting on 9th April 2024. JRCALC consists of expert advisors including those with vascular and surgical knowledge. It was decided that we will develop some new guidance for paramedics to be more aware that some surgical wounds, particularly those Chairman: Managing Director: around blood vessels, can become infected and be at risk of catastrophic bleeding. It is likely this will be included in our existing vascular emergencies guidance. We will follow our existing process for the review and update of our guidance and this is expected to take around three months. When the guidance is updated it will be pushed out as a clinical update onto the App following our usual process which involves approvals from JRCALC and our National Ambulance Medical Directors group (NASMeD). If you have any further questions please do not hesitate to get in touch. Yours sincerely Director of Operational Development and Quality Improvement Chairman: Managing Director:
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