Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0284, written 26 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 | 26 May 2024 |
|---|---|
| Reference | 2024-0284 |
| Deceased | David Scott |
| Coroner | Charlotte Keighley |
| Coroner area | Cheshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Warrington Hospital 1 CORONER I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of Cheshire 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 11 October 2023 I commenced an investigation into the death of David SCOTT aged 68. The investigation concluded at the end of the inquest on 23 May 2024. The conclusion of the inquest was that: David Scott died as a consequence of naturally occurring disease contributed to by malnutrition and in part by a delay in the initial diagnosis and treatment of peripheral vascular disease. 4 CIRCUMSTANCES OF THE DEATH On the 2nd February 2023, David Scott attended Warrington Hospital with a history of a non-healing wound to his knee and leg pain. He was diagnosed with a right knee wound infection and discharged with antibiotics. On the 9th February 2023, David was seen by the physiotherapist who reviewed his x-rays and noted some vascular calcification, it was identified that David presented with risk factors for peripheral vascular disease and so it was requested that further investigations be carried out which resulted in an urgent referral being made to the vascular team on the 8th March 2023. By the 4th April 2023, David’s knee wound had increased in size, showing no signs of healing, he was in pain and struggling with his mobility. At this time he had not had any communication in respect of the referral and so attended the Accident and Emergency Department at Warrington Hospital where the non healing ulcer on his right knee was noted, along with swelling and redness to both legs. David was admitted for review by the vascular team and on the 7th April 2023, investigations confirmed chronic limb threatening ischaemia in both of David’s legs in the context of peripheral vascular disease, at which time, surgical treatment options including revascularisation and endovascular were considered appropriate. By the 14th April, David’s required assistance to mobilise and there was a deterioration in the wound to his knee with it appearing black and more inflamed with further blackened wounds appearing on his heel and ankle. During the period of deterioration, David’s wounds were not reviewed by the tissue viability nursing team as no referral had been actioned. On the 18th April 2023, David was treated with antibiotics for infection and when he was seen by the vascular surgeon on the 21st April, the condition of his leg had deteriorated to the point of ischaemic gangrene which had become so severe that he required an above the knee amputation as his leg was beyond repair. On admission, David was considered to be at high risk of malnutrition and during the admission, he lost weight Regulation 28 – After Inquest Document Template Updated 30/07/2021 following a reduction in his oral intake. On the 26th April 2023, David was transferred to the Countess of Chester Hospital for surgery and on arrival it was noted that he had already started to develop deep tissue injury to his hip and buttocks. In the weeks that followed, amputation surgery was completed along with bypass surgery for revascularisation of his lower limbs. David continued to lose weight and experience difficulties with his skin integrity. He required 24 hour nursing care and was transferred to Green Park Nursing home to enable his wounds to heal with a view to his care eventually being moved back into the community. Whilst at Green Park, David gained weight and some of his wounds improved, however by the end of September, David was struggling to manage his pain, he looked pale and tests indicated that he had developed an infection. On the 30th September 2023, David was admitted to Warrington Hospital with a diagnosis of infected ulcers and osteomyelitis. He did not respond to treatment and so palliative care commenced, following which, his condition deteriorated and he passed away on the 7th October 2023. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) When Mr Scott attended Warrington Hospital on the 2nd February 2023, having been advised to do so by his GP and the GP having liaised with the hospital in respect of their concerns relating to a non-healing wound on Mr Scott's knee, an x-ray was taken which showed evidence of vascular calcification which was not noted in the x-ray report. Mr Scott was diagnosed with a right knee wound infection and discharged with antibiotics. Seven days later a physiotherapist reviewed Mr Scott and considered the x-rays as part of his review. The physiotherapist noted some vascular calcification on the x-ray, which raised concerns of peripheral vascular disease given Mr Scott's clinical presentation and history. Further information was provided to me in writing from a Consultant in Emergency Medicine and a Consultant Radiologist, as to why the vascular calcification was not recorded in the original x-ray report. I was informed that this was because blood vessel calcification can be a normal age related finding and the calcification was of minimal vascular calcification which could be normal. Having considered the second edition of the Standards for Interpretation and Reporting of Imaging Investigations produced by the Royal College of Radiologists and having heard oral evidence from a Consultant Vascular Surgeon that a non-healing wound in addition to vascular calcification evident on x-ray can be a clinical indicator for Peripheral Vascular Disease which would then trigger a further process of investigation, I am concerned that a finding that 'could be normal' and so conversely 'could be abnormal' was not recorded. I am further concerned and that something of this nature, would not be expected to be noted in the x-ray report, it appearing to be considered standard practice for it not to be reported by both a Consultant in Emergency Medicine and Consultant Radiologist within Warrington Hospital. This does not appear to be consistent with expected standards and poses a risk that future deaths may occur. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 In my opinion action should be taken to prevent future deaths and I believe you (and/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 July 21, 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 Persons I have also sent it to who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 26/05/2024 Charlotte KEIGHLEY Assistant Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
INHS. Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Wing, Warrington and Halton Hospitals Foundation Trust Lovely Lane, Warrington, Cheshire WAS 10G Email: Our Ref: 15154 Date: 17 July 2024 Ms Keighley Assistant Coroner Cheshire Coroner’s Court Museum Street Warrington WA1 1JA Dear Ms Keighley Re: Inquest into the death of Mr David Scott We write regarding the inquest into the death of Mr Scott which concluded on 22 May 2024 in which you issued a Regulation 28 Report to Prevent Future Deaths (“Regulation 28 Report’). May we take this opportunity to express our sincere condolences to the family of Mr Scott. We understand that the Regulation 28 Report was issued on the basis that vascular calcification was not reported on a knee X-Ray performed in the Emergency Department in February 2023. We understand that your concern is that such a finding, which could be normal or abnormal, was not included in the X-Ray report and you are concerned that the non-inclusion of such a finding in future reports poses a risk that future deaths may occur. We, along with the medical teams in the Emergency Department and Radiology Department, have carefully considered your conclusion and outline below our response and the actions which the Trust will undertake to reduce the risk of further such harm. For clarity these are presented below in 3 subsections: 1 Clinical assessment of leg ulcers and recognition of peripheral vascular disease in the Emergency Department. 2 Completeness of clinical details on imaging requests. 3. Reporting standards in the context of incidental findings. Chief Executive: INHS Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Wing, Warrington and Halton Hospitals Foundation Trust Lovely Lane, Warrington, Cheshire WA5 1QG Email : 1. Clinical assessment of leg ulcers and recognition of peripheral vascular disease in the Emergency Department Peripheral Vascular Disease (PVD) is typically a clinical diagnosis, which is then initially investigated with Doppler USS before usually being confirmed and further characterised with CT Angiography. This diagnostic process requires an initial index of suspicion for PVD during the assessment of leg wounds, with a painful non-healing ulcer prompting further history taking and clinical examination to elicit other clinical features of PVD. This did not occur in Mr David Scott's case. To reduce the risk of a future similar omission, we will ensure that all of our Emergency Department Medical Team receive further training and education In the clinical assessment of leg wounds and vascular assessment of patients with chronic limb wounds. 2. Completeness of clinical details on imaging requests Had the clinical assessment correctly raised the suspicion of PVD (as outlined above) this would have prompted additional imaging in addition to a plain X ray to effectively investigate for possible PVD. Similarly had the imaging request included information regarding the nature of the wound (specifically it being non-healing and painful), this would have raised the clinical suspicion of the wound being an ischaemic injury and likely elevated the vascular calcification seen on X ray from a common and asymptomatic incidental finding to a more important part of the clinical picture. In the absence of the above relevant clinical information, in line with national reporting standards, the reporting radiologist had no reason to suspect that the vascular calcification was of any clinical significance and as such this was not reported nor were alternative, more appropriate investigations for PVD advised by the reporting radiologist. Effective reporting is dependant or accurate and-complete clinicaHnfermation-on imaging requests, which were lacking in this case. Our Radiology Department will work with the Emergency Department to undertake specific education and teaching with regards to the standards and quality of clinical information required to ensure effective reporting. To ensure that change is sustained and to identify further areas for learning and improvement, the Emergency Department and Radiology Department will undertake a joint clinical audit of the quality of clinical information on imaging investigation requests at a frequency to be determined based on the findings of the first baseline audit. Chair: Chief Executive: 9991990611 NHS Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Wing, Warrington and Halton Hospitals Foundation Trust Lovely Lane, Warrington, Cheshire WAS 10G Email : 3. Reporting standards in the context of incidental findings As stated in the written evidence submitted to the inquest, vascular calcification is common in older patients and is often seen incidentally on imaging studies in patients without clinical features of PVD. Studies suggest the prevalence of vascular calcification increases with age, and it is not routinely reported unless clinical information on the imaging request is suggestive of a clinical diagnosis of PVD, the calcification is severe or is associated with an aneurysm. The presence and extent of vascular calcification on X-ray does not correlate with PVD symptoms or severity and for this reason, X-rays are not used in the diagnosis of peripheral vascular disease. Mr Scott's knee X-Ray showed mild vascular calcification without evidence of an aneurysm and therefore, in the absence of clinical information suggestive of PVD on the imaging request, this finding was not mentioned in the report. Our Radiologists confirm this is in line with national practice and guidance (the Standards for Interpreting and Reporting of Imaging Investigations produced by the Royal College of Radiologists). The Radiology Team have tabled an agenda item at the Radiology Governance Meeting for wider discussion of this case and associated issues as outlined above. This meeting is due to take place on 19 August 2024. Our Radiologists will also present this case and your concerns to the Cheshire and Merseyside Radiology Imaging Network (CAMRIN), a collaboration of 12 Trusts from across the Cheshire and Merseyside Integrated Care System (ICS) that have come together to work on a large-scale change programme that aims to improve radiology services for patients and staff. This meeting is due to take place on 17 September 2024. The Trust is always keen to review, learn and wherever possible, strengthen our clinical processes and so we are grateful for your bringing these concerns to our attention. We hope the above offers you reassurance of the Trust’s ongoing commitment to managing patient safety risks and continually improve the services we provide. Yours sincerely Chief Nurse Chair Chief Executive: 999199061.1 INHS| Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Wing, Warrington and Halton Hospitals Foundation Trust Lovely Lane, Warrington, Cheshire WA5 1QG Email :
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