Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0207, written 19 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Apr 2024 |
|---|---|
| Reference | 2024-0207 |
| Deceased | Richard Hardman |
| Coroner | Adrian Farrow |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University 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 THIS REPORT IS BEING SENT TO: 1. NHS ENGLAND 2. GREATER MANCHESTER INTEGRATED CARE 1 CORONER I am Adrian Farrow, Assistant Coroner, for the coroner area of Greater Manchester South 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 10th August 2023, an investigation was commenced into the death of Dr Richard George Hardman, aged 77 years. The investigation concluded at the end of the inquest on 20th March 2024. The conclusion of the inquest was that the medical cause of death was: 1a) Aspiration Pneumonia 1b) PEG feeding 1c) Oropharyngeal Dysphagia due to Bulbar Myopathy due to radiotherapy for Tonsillar Cancer (2001) and Parkinson’s disease The conclusion as to his death was that he died from aspiration pneumonia which arose as a result of a combination of natural disease and recognised effects of necessary medical treatment. 4 CIRCUMSTANCES OF THE DEATH Dr Hardman underwent radiotherapy in 2001 for tonsillar cancer and after a number of years developed dysphagia which was later found to be a late onset side effect of the cancer treatment. He was at risk of aspiration due to hypersalivation and mucus secretions, such that a PEG tube was inserted in July 2022 to mitigate the risk. He developed symptoms of and was diagnosed with Parkinson’s disease by a consultant neurologist. Parkinson’s disease further compromised his ability to swallow and breathe. By May 2023, his respiratory system was significantly compromised, he was under the care and supervision of the North West Ventilation Unit (NWVU). There were difficulties in identifying both the provider of a suction machine and training in the use of a suction machine at home, as he did not live within the immediate geographical area of the NWVU from which the recommendation for a suction machine came with the result that the machine was unavailable for a period of about a month. Dr Hardman then suffered a spontaneous sigmoid volvulus which was resolved as an in- patient, but without surgical intervention. On 7th August 2023, Dr Hardman became unwell and on admission to hospital, was found to have aspiration pneumonia and a partial sigmoid volvulus confirmed at post- mortem. The evidence in the inquest strongly suggested undetected gastroparesis and the post- 1 mortem examination revealed evidence of chronic aspiration. There were a number of different medical disciplines involved in Dr Hardman’s treatment and care across a number of different NHS hospitals, but the absence of any lead practitioner meant that there was no global oversight of the various complex interacting conditions and care and whilst the inquest did not find evidence to say, had such a lead practitioner been in place, that Dr Hardman’s life would have been prolonged or saved, the potential for more collaborated, holistic care was clearly apparent which could in patients with complex multi-disciplinary needs, prevent death. 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. – The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations 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 14th June 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 Person: to the Chief Executives of the Manchester University NHS Foundation Trust and the Stockport NHS Foundation Trust. on behalf of Dr Hardman’s family. I am also sending copies 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. 9 Adrian Farrow HM Assistant Coroner 19.04.2024 2
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.
Inquest Index ~S1 | ~S3 | ~S4 | SECTION A – Responses Document Date Author Pages Regulation 28 Response GMIC Regulation 28 Response - NHSE 21/06/2024 A1 – A2 08/07/2024 A3 – A5 ~E ~E ~E E: Date: Private & Confidential Mr Adrian Farrow H M Assistant Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr. Farrow, Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 19 April 24 regarding the sad death of Richard Hardman. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Richard’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 20th March 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient. This case, as you have described, is very complex in nature and spans specialist services, acute services, and community/primary care services. Generally speaking, the clinician taking care of the most pressing or main issue by default usually take the lead, this is simpler in one setting such as an acute hospital but is complicated when care spans across different settings and services. We have different mechanisms in place that span services to support better communication and co- ordination of care. This includes a ‘joint’ care record that exists across Greater Manchester (the GM Care Record) which holds information from various organisations including GP Practices, Acute Trusts, Adult Social Care (Local Authority) and Mental Health Trusts. Most clinicians have access to this system and to provide an indication of how often it is used, in March 2024, 760 individual acute trust staff accessed records 12,519 times, viewing 7,997 patients. 4th Floor, Piccadilly Place, Manchester M1 3BN A1 Whilst data tells us that the system is being accessed and patient information being appropriately shared via the GM Care Record, it is acknowledged that not all health care professionals are accessing the benefits of this system. There is a program of work currently underway with a plan to update the web page and re-launch the GM Care Record in early June 2024. The re-launch aims to raise awareness further and eLearning has been updated in addition to which additional training will be provided on how to access and use the system. I have included below links to additional information about the GM Care Record which I hope will be helpful to you: - • • • www.gmwearebettertogether.com (public facing information) www.gmwearebettertogether.com/training (training information) The GM Care Record - Health Innovation Manchester (info for health & social care teams ) In circumstances where a patient is being cared for across multiple specialist areas, information is shared within the GM Care Record, which supports but is not intended to replace a face-to-face MDT process where the overall care of a patient can be discussed. Technology such as Microsoft Teams enables representatives in multiple organisations’, regardless of location (not just within GM), to ‘meet’ to discuss individual patients and this is a process that happens regularly. In terms of the specialist services provided by the North West Ventilation Unit there is a Long-Term Ventilation Service (LTVS). When dealing with patients with complex medical issues, the LTVS provides regular and "ad hoc” urgent nurse-led and consultant-led appointments. Patients have access to a 24h helpline. When their patients are admitted to another hospital, we have a dedicated staff member to provide advice to those care teams. For frail patients we provide home visits. These complex cases are discussed at the weekly multidisciplinary team meeting that are minuted, and we communicate with other services regularly. This service recognises the need to appoint care coordinators for patients with complex medical needs and progress to achieve this continues. We intend to also take this case to our Clinical Effectiveness Group on the 25th of July 2024, to explore further what more we can do to support complex medical cases. We will also look to check and challenge the robustness of escalation routes from health professionals, patients and families/carers when it comes to concerns, support needs and the provision of equipment. Best wishes 4th Floor, Piccadilly Place, Manchester M1 3BN A2 Mr Adrian Farrow HM Assistant Coroner Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 8 July 2024 Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Dr Richard George Hardman who died on 07 August 2023 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 April 2024 concerning the death of Dr Richard George Hardman on 07 August 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dr Hardman’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Dr Hardman’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Dr Hardman’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them. In your Report, you raised a concern that there was no obvious mechanism for the various medical disciplines across the different hospital sites to be brought together, in complex medical cases, under the leadership of a single practitioner. In Dr Hardman’s case, you raised that the absence of any lead practitioner meant that there was no global oversight of the various complex interacting conditions and care, and the potential for more collaborated, holistic care was clearly apparent. We note that you have also addressed your Report to the Greater Manchester Integrated Care Board (GM ICB) and they are better placed to address your concern regarding processes across the Greater Manchester system for management of patients with complex medical needs, under the care of different specialties. NHS England has however engaged with GM ICB on the concerns raised. GM ICB advise that there is a ‘joint’ care record that exists across Greater Manchester (the GM Care Record) which holds information from various organisations including GP Practices, Acute Trusts, Adult Social Care (Local Authority) and Mental Health Trusts. Most clinicians have access to this system and, to provide an indication of how often it is used, in March 2024, 760 individual acute trust staff accessed records 12,519 times, viewing 7,997 patients. A3 In circumstances where a patient is being cared for across multiple specialist areas, information is shared within the GM Care Record, which supports but is not intended to replace a face-to-face Multidisciplinary Team (MDT) process where the overall care of a patient can be discussed. Technology such as Microsoft Teams enables representatives in multiple organisations, regardless of location (not just within GM), to ‘meet’ to discuss individual patients. We refer you to the response from GM for further information. The Complex Home Ventilation (CHV) Service specification describes the tertiary hospital infrastructure necessary to enable the safe and sustainable establishment and maintenance of home care packages for patients with complex ventilation needs. The overall aim of the specialist service is to establish and support patients with long-term breathing difficulties on the least intrusive ventilation modality possible. This will enable them to have a longer life of better quality than would otherwise be possible. When dealing with patients with complex medical issues, the Long-Term Ventilation Service (LTVS) within Greater Manchester provides regular and "ad hoc" urgent nurse-led and consultant-led appointments and patients have access to a 24-hour helpline. When their patients are admitted to another hospital, there is a dedicated staff member to provide advice to those care teams and home visits are provide to frail patients. These complex cases are discussed at the weekly Multidisciplinary Team meetings which are minuted and communicated with other services regularly. The service recognises the need to appoint Care Coordinators for patients with complex medical needs. The issue of access to the LTVS and geographical location has been discussed with my Specialised Commissioning colleagues. There is an LTVS for each Integrated Care Board / System within the North West Region. The LTVS are not responsible for the provision of suction machines, which would be the responsibility of the Community Team to provide. The LTVS should refer any request for a suction machine back to the local/referring clinician/consultant involved in the patient’s care. My regional colleagues in the North West will also be following up with the Manchester University NHS Foundation Trust following a Clinical Effectiveness Group meeting later in July 2024, which will consider the issues raised in your Report. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, A4 National Medical Director A5
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