Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0144, written 14 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2024 |
|---|---|
| Reference | 2024-0144 |
| Deceased | Ernest Smith |
| Coroner | Sonia Hayes |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Princess Alexandra Hospital NHS 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer of Princess Alexandra NHS Trust 1 2 3 4 CORONER I am Sonia Hayes, Area Coroner, for the coroner area of Essex 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 20 April 2023 an investigation was commenced into the death of Ernest Smith, aged 77 years. Ernest Smith died on 10 April 2023. The investigation concluded at the inquest on 26 February 2024. The conclusion of the inquest was narrative: Mr Smith developed to prophylactic anticoagulation for venous thromboembolism. Mr Smith developed septic infection that did not respond to treatment. leg haematoma secondary left With a medical cause of death of 1a Sepsis 1b Hospital Acquired Pneumonia and Infected Haematoma 1c Haematoma Secondary to Anticoagulation, 2 Type II Diabetes Mellitus, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease CIRCUMSTANCES OF THE DEATH Ernest Smith died at the Princess Alexandra Hospital on 10 April 2023 due to Sepsis due to Hospital Acquired Pneumonia and Infected Haematoma. The Haematoma was secondary to Anticoagulation in a background of Type II Diabetes Mellitus, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease. Mr Smith was admitted to hospital on 22 February 2023 unwell. Mr Smith received prophylactic anticoagulation to prevent blood clots and was noted to have stripe type bruising on his lower limbs on 10 March and required a medical review that was undertaken on the evening of 12 March and the anticoagulation was stopped on 13th March following the development of a left 1 leg haematoma requiring surgical evacuation and debridement. Mr Smith was discharged for rehabilitation on 17 March and readmitted on 23 March with bleeding from the haematoma. Mr Smith was noted to have purulent infection on 30 March and the surgical team awaited advice from Broomfield Hospital. Antibiotics were commenced on 3 April and Mr Smith was septic on 4 April and underwent debridement of his haematoma on 5 April. Mr Smith continued on antibiotic therapy on the advice of microbiology and developed pneumonia, he deteriorated over 9th April and 10 April. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – a. Medical review requested on 10 March by nurses due to concerns about the acute development of bilateral bruising on Mr Smith’s legs. This request was chased by nurses on 11 March and was not conducted until the evening of 12 March. b. A further medical review was conducted in the early hours of 13 March as Mr Smith was in pain and had developed a leg haematoma. It took 3 days for consultant review of Mr Smith. On 13 March Mr Smith was reviewed by a consultant from another ward and prophylactic anticoagulation was discontinued. c. d. Mr Smith was medically reviewed and considered fit for discharge on 30 March. A tissue viability nurse review that day noted an infected for leg haematoma and consideration of washout and debridement. recommended a surgical referral 6 7 e. Antibiotics for the infected haematoma were not commenced until 3 April. f. Sepsis was highlighted by the Trust surgical team on 3 April and the Sepsis Protocol was not followed. . 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 9 May 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 2 proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Wife of Mr Smith 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. 8 9 14 March 2024 HM Area Coroner for Essex Sonia Hayes 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.
Hamstel Road
Harlow
Essex
CM20 1QX
7th May 2024
Private and Confidential
Area Coroner Sonia Hayes
Essex Coroner’s Court
Chelmsford County Hall
Victoria Road
Chelmsford
CM1 1QH
Dear Coroner Hayes,
I write in the matter of the late Ernest Smith in response to your recent Regulation 28 Report
to prevent future deaths.
Mr Smith was admitted to Princess Alexandra Hospital on 22nd February 2023 following a
fall. He tested positive for Covid-19 and was transferred to Kingsmoor ward whilst waiting for
a care package before he could be discharged. He was asymptomatic on the ward until 11th
March when he developed a painful swelling on his left calf. This was scanned and
increased in size and noted to be a haematoma. His VTE prophylaxis (Heparin) was stopped
and on 13th March he had an evacuation procedure undertaken by the Orthopaedic team.
On 15th March he was discharged to St Margaret’s Hospital for rehabilitation.
Mr Smith was readmitted to Princess Alexandra Hospital on 24th March where he was cared
for on Winter ward. His case was discussed by the Orthopaedic team and in accordance
with established protocol, advice regarding his haematoma was requested from the plastic
surgery team at Broomfield Hospital. The advice from Broomfield was received on 4th April
whereupon a wash out and debridement of his haematoma took place on 5th April.
Unfortunately despite on-going care, Mr Smith deteriorated and sadly passed away on 10th
April 2023.
I note that the areas of concern which you have raised appear to relate to three distinct
points. To address these points, we have developed a number of actions. Whilst some are
still ongoing, I am confident that the Trust is on course to deliver the necessary changes to
ensure that there are no further risks of severe harm or deaths from the points you have
raised.
Points a b & c- A delay in conducting a medical review
We agree that there was a delay in conducting a medical review for Mr Smith from Friday
10th until Sunday 12th March. Since Mr Smith’s admission, the doctors on call now have an
additional formal ‘tasks’ list using an established software tool called Nervecentre. All
outstanding ‘tasks’ relating to patients are now articulated between day and night
teams during the clinical handover of patients using this list. Coordination for the
care of patients out of hours is the responsibility of a dedicated Hospital at Night team.
Point d & e – A delay in the administration of antibiotics from Thursday 30th March until
Monday 3rd April.
We agree that there was a delay in commencing intravenous antibiotics. However, Mr Smith
was prescribed a broad spectrum oral antibiotic (Doxycycline) which would have been
appropriate for his haematoma, given his allergy to Penicillin. Despite him having declined
the first dose on 25th March, it was then administered 100mgs daily from 26th March.
Point f- A failure to reinforce the Sepsis 6 protocol.
We agree that we did not implement ‘Sepsis 6’ formally in Mr Smith’s case. Since his
episode of care, we have taken steps to improve the management of Sepsis at the Trust. We
have been successful in recruitment into a Sepsis Lead Nurse position. This role includes
ensuring Trust-wide compliance with the Sepsis 6 protocol. She is currently working towards
ensuring 100% compliance to Sepsis training in all of our clinical areas, and the inclusion of
Sepsis training as part of our mandatory training programme for all clinical staff, to be
extended in due course to non-clinical staff.
We have also implemented a Sepsis awareness programme, part of which included a Sepsis
Awareness Day on 21st March 2024 which was well very attended by staff. We remain
committed to cyclical audits and improvement programmes relating to Sepsis.
I hope this letter helps address the concerns raised in your Regulation 28 notice for
prevention of future deaths.
Please do not hesitate to contact me if you require any further details.
Yours sincerely
Medical Director
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