Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0287, written 29 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 | 29 May 2024 |
|---|---|
| Reference | 2024-0287 |
| Deceased | John Hartey |
| Coroner | Chris Morris |
| 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: Rt. Hon. Victoria Atkins MP, Secretary of State for Health and Social Care CORONER I am Chris Morris, Area Coroner for Manchester South. 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 INVESTIGATION and INQUEST On 3rd April 2024, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of John Richard Hartey who was found dead at his home on 20th October 2023, aged 57 years. The investigation concluded with an inquest which I heard on 3rd May 2024. A post mortem examination determined the medical cause of Mr Hartey’s death as being:- 1) a) Congestive cardiac failure; b) Hypertensive heart disease; c) Type 1 Diabetes Mellitus II) Acute bronchitis and transplant immunosuppression The conclusion of the inquest was a Narrative Conclusion of natural causes contributed to by recognised complications arising from transplant immunosuppression. CIRCUMSTANCES OF THE DEATH Mr Hartey was found dead at his home on 20th October 2023 as a consequence of congestive cardiac failure against a background of hypertensive heart disease and Type 1 Diabetes Mellitus. His death was contributed to by acute bronchitis and transplant immunosuppression. 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 MATTER OF CONCERN is as follows. – The court heard evidence to the effect that in the days prior to his death, Mr Hartey’s General Practitioner had made an Urgent Referral to the local District Nursing service which was received on 19th October 2023. Mr Hartey was allocated the first available appointment which was not until 23rd October 2023. It is a matter of concern that a national shortage of District Nurses / Community Specialist Practitioners can lead to a delay in patients being seen in accordance with their needs. 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 24th 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 Mr Hartey’s sister. I have also sent a copy to Urmston Group Practice and Manchester University NHS Foundation Trust 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. Dated: 29th May 2024 Signature: Chris Morris, HM Area Coroner, Manchester South.
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.
Our ref: Mr Chris Morris HM Area Coroner for Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG By email: Dear Mr Morris, Minister of State for Care 39 Victoria Street London SW1H 0EU 22 August 2024 Thank you for the Regulation 28 report of 29 May 2024 sent to the Department of Health and Social Care about the death of John Richard Hartey. I am replying as the Minister with responsibility for community health services. Firstly, I would like to say how saddened I was to read of the circumstances of John Richard Hartey’s death, and I offer my sincere condolences to their 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 that a national shortage of District Nurses and Community Specialist Practitioners can lead to a delay in patients being seen in accordance with their needs. In preparing this response, departmental officials have made enquiries with NHS England. The correct staffing levels are key in delivering safe care. NHS England has developed a national Community Nursing Safer Staffing Tool which is being offered to community nursing providers to support them with identifying the right staffing levels. The tool can help to identify gaps in the service and enable strategies to be developed locally to address any shortfall in workforce numbers. This tool calculates clinical staffing requirements based on patients’ needs (acuity and dependency) which, together with professional judgement, guides chief nurses in their safe staffing decisions. We have set out a clear commitment to move to a neighbourhood health service, with more care delivered in local communities to spot problems earlier, this includes over time shifting resources to primary care and community services. In the longer term, we are committed to training the staff the NHS needs to be there for patients when they need it. Minister of State for Care 39 Victoria Street London SW1H 0EU Demand is increasing nationally for community and district nursing services, and we have been informed that there is a high demand for district nursing services in the Trafford locality. The Trafford district nursing service operates clinical triage, to ensure patients are seen as timely as possible. The organisation is working to review the service specification with commissioners, to provide necessary assurance and response based on clinical need in the future. A recruitment and retention strategy launched on 16th July by the Manchester University NHS Foundation Trust, with recruitment events held in April and May and July, aim to increase service capacity. Four posts have also been offered as part of the "guaranteed jobs" programme to newly qualified staff and staff turnover has improved from 20.9% June 2023 to 10.7% May 2024. Service transformation across the Trafford locality has brought together care to support discharge and provide urgent community response services. The implementation of the new model has meant an increase in establishment in the team, allowing development of the crisis service to meet the 2-hour response national standard. These changes have been important to support patient flow in and out of hospital but have not reduced the demand on district nursing services in the area which has seen an increase in referrals of 15% in 2023/24. There are ongoing discussions between the Integrated Care Board, Manchester University NHS Foundation Trust and Trafford Local Care Organisation (TLCO) in relation to the funding of the TLCO Community Services, recognising the capacity challenges. I hope this response is helpful. Thank you again for bringing these concerns to my attention. Yours sincerely,
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