Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0249, written 7 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 May 2024 |
|---|---|
| Reference | 2024-0249 |
| Deceased | Peter Fanning |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham 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. University Hospitals Birmingham NHS Foundation Trust CORONER I am Louise Hunt, HM Senior Coroner for Birmingham and Solihull 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 8 January 2024 I commenced an investigation into the death of Peter Jason FANNING. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural causes CIRCUMSTANCES OF THE DEATH Peter was born with cerebral palsy which caused severe physical impairment. He communicated using a liberator device and received a full package of care at home. He was fed using a gastrostomy tube with a jejunal extension which became dislodged periodically and he suffered from epilepsy and episodes of aspiration pneumonia. In 2022 and 2023 there were repeated dislodgments of his feeding tube resulting in him being admitted to hospital for replacements which impacted on his nutritional state and frailty. He was admitted to the Birmingham Heartlands Hospital on 07/11/23 after a further dislodgement of his feeding tube which was replaced on 15/11/23 due to there only being one radiology list per week for complex feeding tube replacements. He was discharged home on 18/11/23. The feeding tube dislodged again requiring further admission on 24/11/23. The tube was reinserted on 28/11/23 but unfortunately became dislodged again on 30/11/23. Peter was treated for severe pneumonia on 30/11/23. A PICC's line was inserted on 05/12/23 to provide total parenteral nutrition until a further more permanent feeding tube could be inserted surgically on 13/12/23 but this PICCS line also dislodged on 07/12/23 and had to be replaced on 11/12/23. Peter deteriorated with further symptoms of pneumonia on 15/12/23 and sadly died on 19/12/23. Following information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1 2 3 4 1a Pneumonia 1b Frailty 1c II Epilepsy, Cerebral Palsy CORONER’S CONCERNS 5 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. – 1. The inquest heard evidence that there is only one radiology list per week to accommodate replacement of feeding tubes in patients with complex needs. In Peter’s case this meant he had to wait a week for the tube to be replaced meaning he had suboptimal nutrition during this period. Consideration should be given to whether additional services are required for replacement of feeding tubes in patients with complex needs. 2. The inquest heard evidence that Peter’s nutritional status was suboptimal due to repeated tube dislodgments and waiting for radiology or theatre slots to be available. Consideration needs to be given as to how best to maintain patients’ nutrition after tube dislodgments when they rely on feeding tubes. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 2 July 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : 6 7 8 I have also sent it to the Medical Examiner, ICS, NHS England, CQC, who may find it useful or of interest. 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. 7 May 2024 9 Signature: Louise Hunt Senior Coroner for Birmingham and Solihull
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.
2 July 2024 Mrs Louise Hunt HM Senior Coroner for Birmingham and Solihull By way of email only: Dear Mrs Hunt Inquest touching the death of Peter Jason Fanning Response to Regulation 28 Report to prevent future deaths I am writing in response to the Regulation 28 notice issued following the conclusion of the inquest on 7 May 2024, into the sad death of Peter Jason Fanning on 19 December 2023 at Birmingham Heartlands Hospital (part of University Hospitals Birmingham NHS Foundation Trust (UHB). We have carefully considered the concerns raised within your report to prevent future deaths, which surrounds the availability of the service to replace feeding tubes in patients with complex needs having heard evidence that there is one list per week for replacement feeding tubes to be sited. You were also concerned as to how nutritional needs would be met once a feeding tube had become dislodged when a patient is reliant on the feeding tube for nutrition. Concern 1 – delays in insertion of replacement feeding tube in complex patients due to access to radiology lists being available only once per week. With regard to radiology capacity available to support placement of feedings tubes, there are two aspects to this. Firstly, is the provision of enteral feed where x-ray guidance to assist tube insertion is required and secondly where provision of intravenous line insertions are required for parenteral nutrition. X-ray guided tube insertion The Interventional Radiology department has increased capacity from one to four intervention radiology (IR) lists per week across our Heartland’s, Good Hope and Solihull Hospital sites (HGS), which can accommodate x-ray guided feeding tube insertions. We also now have three IR consultants who are able to provide this service (increased from one previously) and these changes have been in place since April 2024. Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full- time provision. Patients who require anaesthetic input, due to their particular complex needs, require the support of the emergency theatre anaesthetic team on our HGS sites. This team also covers two emergency operating theatres, so cases (surgical and IR) are prioritised accordingly based on clinical urgency. This support fluctuates because it is dependent on the skill mix of the team covering theatres. Clinical teams may, in a small number of cases, be advised by the IR team to liaise with colleagues from other UHB sites, to ascertain if support can be provided on the Queen Elizabeth Hospital (QEH) site for example. QEH IR has more robust access to anaesthetic support and therefore is better equipped to manage these general anaesthetic cases. As on our HGS sites, QEH IR support is dependent on suitable bed availability and IR capacity on that site at the time of the request. We are currently reviewing our service where general anaesthetic is required and this includes consideration of increasing this provision on our Heartlands site to enable us to better meet the needs of our more complex patients in a more timely manner. Yours sincerely Chief Executive
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