Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0214, written 12 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 | 12 Apr 2024 |
|---|---|
| Reference | 2024-0214 |
| Deceased | Sabina Wood |
| Coroner | Louise Rae |
| Coroner area | Blackpool and Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
(1) Medical Director, Blackpool Teaching Hospital NHS Foundation
Trust
(2) Minister of State, Department of Health
1 CORONER
I am Louise Rae, Assistant Coroner, for the area of Blackpool & Fylde.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
The death of Sabina Wood on 27th January 2023 was reported to Blackpool
Coroner’s Court and an investigation opened on 7th February 2023 which was
concluded by way of an inquest held on 11th and 12th April 2024.
I determined that the medical cause of Sabina’s death was:
1(a) Acute harmorrhagic pancreatitis
1(b) Chloelithiasis
The conclusion of the Coroner was that this death was a Natural Death.
4 CIRCUMSTANCES OF THE DEATH
I returned the following in box 3 of the Record of Inquest recorded:
Sabina Wood was admitted to the Blackpool Victoria Hospital on 11th January
2023 following complaining of right upper quadrant pain which she had been
experiencing intermittently for a few months. A CT scan revealed the presence
of gallstones and the possibility of stones in the bile duct. A MRCP scan was
performed on 12th January 2023 which showed bile duct stones alongside
1
evidence of inflammation of the gallbladder. An ERCP was performed on 23rd
January 2023 which did not find gallstones in the bile duct. Sabina discharged
herself from the Blackpool Victoria Hospital at 19.40 on 23rd January 2023 against
medical advice. She had the capacity to self discharge herself from the hospital.
Sabrina contacted North Shore GP Practice on 24th January 2023 complaining of
pain in the region where the ERCP was performed and was prescribed oral
morphine by the pharmacist following a telephone consultation taking place.
Sabrina did indicate any symptoms other than pain and did not tell the pharmacist
that she had left the hospital against medical advice. On 25th January 2023
Sabrina contacted the GP Practice and had a telephone consultation with
.
During this consultation she did not describe any new symptoms and said that the
morphine prescribed the day before was helping. On 27th January 2023, Sabina’s
partner found her unresponsive in bed. Paramedics attended and confirmed her
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 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:
I heard extensive evidence on the practice of preparing hospital discharge
summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a
patient is ready for discharge. I found that this occurred across disciplines and
hospitals given that
now works at the Royal Preston Hospital as a
Consultant where I heard the practice also takes place. The rationale explained
to me was that discharge summaries were created early and worked on
throughout patient stays. This was to save time and to prevent lengthy summaries
being written at the end of long stays for patients. I heard from
, Head
of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s
practice is different and it is for individual doctors to decide how they create and
complete discharge summaries. I found that there is no process or procedure for
discharge summaries to be created prior to discharge taking place at the
Blackpool Victoria Hospital.
created the document on 20th January 2023 before Sabina
In this case,
underwent the ERCP procedure. This document indicated that the patient was
discharged on medical advice when in fact she self-discharged against medical
advice. The section on ERCP was left blank intending to be completed after the
procedure took place and set out that Sabina was well in herself upon discharge
with pain settling. As the discharge summary was prepared prior to the ERCP
taking place it could not be known whether Sabina was well in herself or that her
pain was settling.
mistakenly clicked on the completed button rather than the save button
on 20th January 2023. There is no mechanism for the IT system to double check
the document is completed before marking the document as complete. The draft
2
discharge summary was sent by staff on 24th January 2023 after Sabina’s self-
discharge on 23rd January 2023. Staff members believed that it was ready to be
sent as it was marked complete by
accepted in her evidence that a draft discharge summary was sent to
Sabina’s GP Practice in error and told me that her revised practice is that she
instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are
undertaking a review which hasn’t yet commenced. This will look at the
development of a policy of how discharge summaries are prepared. This will also
include a review of the IT system with regard to creating and completing discharge
summaries.
I found it very concerning to hear that speculative information in Sabrina’s case
was placed on the discharge summary before her procedure took place. There is
a risk that this could occur again and in the future this may be significant for a
patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by
Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a
correctly completed and finalised discharge summary wouldn’t have changed the
on 25th January 2023 who was told by the patient that she
steps taken by
was improving.
It is however, of vital importance that GPs receive timely and
accurate discharge summaries from hospitals which may be significant in other
cases.
For that reason and not withstanding the review or audit that is about to
commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider
my duty to prevent future deaths is triggered and that there is a risk to of deaths
in the future from this practice which is commonplace and neither medical
specialism or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my
duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
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 7th 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.
3
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:
The family of Sabina Wood
, GP Partner at North Shore Surgery
, Pharmacist at North Shore Surgery
A copy of the report will be circulated to the Medical Director of the Royal
Preston Hospital and North West Regional Hospitals
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
Louise Rae
Assistant Coroner for Blackpool & Fylde
Dated: 12 April 2024
4
2 responses 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.
Trust Headquarters
Blackpool Victoria Hospital
Whinney Heys Road
Blackpool
FY3 8NR
31st May 2024
Ms Louise Rae
Assistant Coroner for Blackpool and Fylde
PO Box 1066
Corporation Street
Blackpool
FY1 1GB
Dear Ms Rae
Re: Regulation 28: Report to Prevent Future Deaths – Sabina Wood
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I would like to offer my sincere
condolences and apologies to the family of Ms Wood.
Thank you for raising your concerns with the Trust, please find below the Trust response to the issues
raised in the report to prevent future deaths.
The preparation of discharge summaries prior to patients being ready for discharge, and
mechanisms for the IT system to double check the discharge document is completed before
marking the document as complete and issuing.
With regard to the IT system in place to provide discharge summaries, to which your concern relates, the
Trust are in the process of replacing the current eDischarge product with one integrated system built upon
the Trust’s Nexus NPR platform, developed in house by our Application Development Team.
The focus of the new solution is to move the existing functionality of the current system (where this adds
value) into the Nexus Patient Record (NPR) environment and further develop functionality to auto populate
as much relevant information into the record as possible from the Trust’s integrated systems.
The new solution will enhance the high-quality exchange of information between the Trust and Primary
Care, following a patient’s admission to hospital. The drivers behind developing the new solution were
manyfold, however the primary focus was increasing patient safety and promoting efficiency in ensuring
that clinical information is shared internally and externally through a robust process. This streamlined
approach will reduce the burden on clinical staff in the collation of discharge summaries, removing the need
to manually pre-populate discharge information in its entirety. It is also expected that the new system will
expedite the process of letters being made available to the primary care colleagues.
RESEARCH MATTERS AND SAVES LIVES – TODAY’S RESEARCH IS TOMORROW’S CARE
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality
up to date care. We are actively involved in undertaking research to improve treatment of our patients.
A member of the healthcare team may discuss current clinical trials with you.
The new solution introduces additional safeguards within the system to prevent discharge summaries being
issued erroneously. The overall discharge now requires that a password is entered by the discharging
clinician before it is issued from the system, thus eradicating the risk of discharge summaries being shared
in an incomplete form.
The implementation of the new NPR eDischarge solution began on 3rd April 2024 in pilot to allow for the
resolution of any technical issues and for essential enhancements to the system to be made on an iterative
basis. Formal roll out began in May 2024, with the system currently in operation across much of the
Integrated Medicine and Integrated Care (IMEC) Division. Full deployment is expected to be completed by
Sunday 30th June 2024.
In the interim whilst system implementation is brought to completion, the Executive Medical Director will
issue a safety instruction to all staff regarding the population of discharge summaries, stating that they need
to take care when pre-populating and that clinicians are not to prejudge any investigation results.
This letter will be shared with colleagues at Lancashire Teaching Hospitals NHS Foundation Trust, so that
learning from Ms Wood’s case is shared across the system.
Yours sincerely
Chief Executive
From Helen Whately Minister of State for Care 39 Victoria Street London SW1H 0EU 13 June 2024 Miss Louise Rae Blackpool Council PO Box 1066 Blackpool FY1 1GB Dear Miss Louise Rae, Thank you for the Regulation 28 report to prevent future deaths of 12 April 2024 about the death of Sabina Wood. I am replying as Minister with responsibility for hospital discharge. Firstly, I would like to say how saddened I was to read of the circumstances of Sabina Wood’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns about a lack of appropriate processes in preparing discharge summaries at Blackpool Victoria Hospital, leading to (in this case) a draft discharge summary including speculative information being sent to the GP in error. Furthermore, I note the report raises the importance of GPs receiving timely and accurate discharge summaries from hospitals. In preparing this response, departmental officials have made enquiries with NHS England. As the Minister responsible for hospital discharge, I recognise the importance of ensuring people are discharged from hospital when they are clinically ready, with the right care and support in place. Your report highlighted concerns that Blackpool Victoria Hospital did not have appropriate processes in place to prepare discharge summaries prior to the patient being discharged from hospital, leading to inaccurate information being incorrectly sent to the GP. NHS England has advised that the medical director of the Blackpool Teaching Hospitals NHS Foundation Trust has issued a letter to all medical staff regarding the population of discharge summaries with key messages to ensure discharge summaries are not prefilled. The trust also has an e- discharge project in place, which is leading on the development and implementation of a new e-discharge process. As part of this process, additional safeguards are being scoped in relation to 'prompts' to check details prior to issue. The standard operating procedures and policy are currently under development and the trust is liaising with Lancashire Teaching Hospitals to share learning and improvements. The ICB has contacted colleagues within the Lancashire South Cumbria ICB trusts to review their processes and the learning will be shared in learning forums. 1 Your report also raises the importance more generally of GPs receiving timely and accurate discharge summaries from hospitals. In the “Delivery Plan for Recovering Access to Primary Care”, ICB chief medical officers are asked to focus on and report their progress against recommendations on how to improve the interface between primary and secondary care. This includes ensuring that discharge letters highlight clear actions for general practice (including prescribing medications required) and establishing single routes for general practice and secondary care teams to communicate rapidly, so that issues with discharge documents can be resolved. In addition to this, NHS England has asked ICBs to report on this work regularly at their public boards, and to use an assessment tool across their secondary care NHS providers, to improve and report on progress as they implement these recommendations. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, HELEN WHATELY
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