Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0082, written 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2024 |
|---|---|
| Reference | 2024-0082 |
| Deceased | Michael Nye |
| Coroner | Alison McCormick |
| Coroner area | Berkshire |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Royal Berkshire Hospital 2 Berkshire and Surrey Pathology Services 1 CORONER I am Alison MCCORMICK, Assistant Coroner, Berkshire for the coroner area of Berkshire 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 18 November 2022 I commenced an investigation into the death of Michael James NYE aged 48. The investigation concluded at the end of the inquest on 07 February 2024. The conclusion of the inquest was that: On advice from his General Practitioner Mr Nye attended the Emergency Department of the Royal Berkshire Hospital at 18.33 on 14th November 2022 suffering from sepsis due to a Streptococcus A skin and soft tissue infection. A single working diagnosis of an upper arm DVT was made by the Emergency Department consultant on call. The Emergency Department was exceptionally busy that night and there were delays in obtaining blood test results, CT scans, escalating Mr Nye’s case to the Intensive Care Unit team and prescribing antibiotics or any other treatment to target sepsis from skin and soft tissue infection. Mr Nye’s condition was observed to deteriorate at about 23.45 and he went into cardiac arrest at about 01.20am on 15th November 2022. A return of spontaneous circulation was achieved after about 3 minutes, but after a CT scan at about 03.00 Mr Nye suffered a further cardiac arrest and resuscitation attempts were unsuccessful. His death was verified at 04.05 on 15th November 2022. On the balance of probability Mr Nye’s death was more than minimally contributed to by: (i) over-crowding in the Emergency Department, lack of a resus bed and pressure on clinical resources; (ii) delay in considering a differential diagnosis of sepsis from skin and soft tissue infection; (iii) delay in obtaining blood test results; (iv) delay in organising and undertaking CT scanning; (v) delay in prescribing antibiotics to target sepsis from skin and soft tissue infection; (vi) delay in escalating his case to the Intensive Care Team. 4 CIRCUMSTANCES OF THE DEATH On advice from his General Practitioner Mr Nye attended the Emergency Department of the Royal Berkshire Hospital at 18.33 on 14th November 2022 suffering from sepsis due to a Streptococcus A skin and soft tissue infection. A single working diagnosis of an upper arm DVT was made by the Emergency Department consultant on call. The Emergency Department was exceptionally busy that night and there were delays in obtaining blood test results, CT scans, escalating Mr Nye’s case to the Intensive Care Unit team and prescribing antibiotics or any other treatment to target sepsis from skin and soft tissue infection. Mr Nye’s condition was observed to deteriorate at about 23.45 and he went into cardiac arrest at about 01.20am on 15th November 2022. A return of spontaneous circulation was Regulation 28 – After Inquest Document Template Updated 30/07/2021 achieved after about 3 minutes, but after a CT scan at about 03.00 Mr Nye suffered a further cardiac arrest and resuscitation attempts were unsuccessful. His death was verified at 04.05 on 15th November 2022. 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) a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed.; b. The burdensome and time consuming out of hours system for clinicians requesting CT scans from an external provider; c. The lack of contemporaneous record keeping in the Emergency Department; d. The lack of a specific night time Internal Escalation Policy. A number of the general Internal Escalation Policy measures are not effective at night; e. The need for training of all Intensive Care Unit clinicians at all levels, both existing Intensive Care Unit clinicians and new joiners, in the policy that a "just to let you know" call should result in an Intensive Care review of the patient; f. The need for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate. 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 April 09, 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 Michael Nye’s family 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 13/02/2024 Alison MCCORMICK Assistant Coroner, Berkshire for Berkshire 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.
r�1:k1 Royal Berkshire NHS Foundation Trust f. T he n�ed for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate The trust's Lead Nurse for Sepsis has delivered focused training in the areas with high prevalence of Sepsis - with teaching sessions in ED as well as discussion at Critical care outreach service (CCORS) and ICU governance meetings. Please see Appendix Bii . I trust this has provided some assurance in some of the changes that are being implemented in ED in order to improve patient safety. Please do not hesitate to contact me should you need any further information. Yours sincerely Chief Medical Officer Pathology Test results returned from lab within reduced time compared to arrival at ED i (Target: reduction of 15 minutes) ii Sepsis Action Plan 2024
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.