Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2024-0092, written 8 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2017 |
|---|---|
| Reference | 2024-0092 |
| Deceased | Paul Gander |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
VERONICA HAMIL TON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC __ GIL VA D.J.TISSHA W, BA(LA W)HONS THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. 2. , Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Road, Brighton. Trust, Royal Sussex County Hospital, Eastern Road, Briahton Head of IT, Brighton and Sussex University Hospitals CORONER I am Veronica HAMIL TON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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. INVESTIGATION and INQUEST On Fifteenth June 2017 I commenced an investigation into the death of Paul Eric GANDER. The investigation concluded at the end of the inquest on Twenty seventh November 2017. The conclusion of the inquest was a NARRATIVE CONCLUSION. CIRCUMSTANCES OF THE DEATH See Record of Inquest 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. I 1 2 3 4 5 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC_ GILVA D.J.TISSHAW, BA(LAW)HONS THE CORONER'S OFFICE WOODYALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 The MATTERS OF CONCERN are as follows: - (1) That at a weekend and out of hours the Consultant Orthopaedic and Trauma Surgeon involved was not able to access the electronic records of other departments within the hospital. This is completely unacceptable. This information is imperative. Arrangements must be made to ensure that full access is given to properly authorised personnel to all hospital records. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25th February 2018. 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. 6 7 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Solicitor 1. 2. 3. Secretary of State for Health, Department of Health 4. 5. Care Quality Commission 6. Clinical Commissioning Group , Chief Executive, NHS England I am also under a duty to send the Chief Coroner a copy of your response. . 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. 2 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC __ GILVA D.J.TISSHA W, BA(LA W)HONS THE CORONER'S OFFICE WOODY ALE, LEWES ROAD BRIGHTON BN23QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 9 Date: am December 2017 SIGNED BY: 1;:4 (~ Senior Coroner Brighton and Hove 3
20 March 2018 Brighton and Sussex University Hospitals NHS Trust Brighton & Sussex University Hospitals St Mary's Hall Eastern Road Brighton BN2 5JF Miss Veronica Hamilton-Deeley HM Senior Coroner for Brighton and Hove Coroner's Office, Woodvale Lewes Road BRIGHTON BN2 3QB Dear Miss Hamilton-Deeley The Late Mr Paul Gander Thank you for your letter of 8 March 2018, together with the report of your expert and the article on this rare complication. With regards to my response of 21 February 2018 to your Regulation 28 report, I am content for you to send it to the Interested Persons and the others you list in your letter. As you know, I take each and every death extremely seriously and the response set out our review, and the changes we have made subsequently. Once again, my heartfelt condolences go to Mr Gander's family and friends. Yours sincerely Chief Medical Officer and Deputy Chief Executive
Brighton and Sussex University Hospitals NHS Trust Brighton & Sussex University Hospitals St Mary's Hall Eastern Road Brighton BN2 5JF Miss V Hamilton-Deeley, HM Senior Coroner Coroner's Office, Woodvale Lewes Road BRIGHTON BN2 3QB Dear Miss Hamilton~Deeley The Late Paul Gander Date of birth: 23.02.1958 Thank you for your letter of 8 December 2017, together with the two Regulation 28 reports and for drawing your concerns to my attention. As you know, we are always willing to review our practices in order to identify improvements which can be made in the light of experience. I II understand that although the Trust was legally represented at the Inquest there was no reference at the Inquest to potential Prevention of Future Deaths (PFD's) Reports being issued. The Trust is concerned at this omission and considers that it has effectively lost the opportunity to avoid parts of the report by not being given the opportunity to make representations at the time. This lost opportunity is applicable with regard to your concerns arising from the Regulation 28 dealing with clinical practice issues, initially in that there were no agreed protocols for the escalation of patients who develop complications from saphenous vein harvesting sites, particularly in regard to whether there should have been a referral to either the Vascular team or the Trauma and Orthopaedic team. You have stated that 'very much time was wasted while this matter was resolved' and that this 'was unacceptable'. The Protocol within the Trust has always been that the Trauma and Orthopaedic team deal with all compartment syndrome injuries, with the exception of compartment syndrome secondary to an acute or acute-on-chronic vascular ischaemia. This evidence was fully explored at the Inquest. Thank you once again for raising your concerns with me. However on behalf of The Trust I must regretfully also raise our own concerns that some of the language contained within the PFD on this issue, in particular the use of the term 'maverick' could be seen as going against the Advice in the Chief Coroner's Guidance Note number 5 which states that Coroners should only use moderate, neutral, well-tempered language. Finally I would be most grateful if you would please pass on my sincere condolences to the family and friends of Mr. Gander. Yours sincerely Chief Medical Officer and Deputy Chief Executive Page 3 of 3
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