Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0306, written 26 Jan 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 Jan 2024 |
|---|---|
| Reference | 2024-0306 |
| Deceased | Michael Pegg |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals NHS 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 THIS REPORT IS BEING SENT TO: 1) 2) Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD; , National Medical Director, NHS England; 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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 On 28 July 2023 I commenced an investigation and opened an inquest into the death of Michael Leslie PEGG. The investigation concluded at the end of the inquest on 23 January 2024 The conclusion of the inquest was that Mr. Pegg “died from natural causes.” 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mr. Pegg come by his death?”, I recorded as follows: “On 13.1.23 Michael Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after suffering two significant seizures at home earlier that morning. Early the following morning he suffered a significant deterioration in his condition and developed pneumonia. Despite treatment, he continued to decline and died in hospital on 15.1.23.” 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. – 1) Over the two days that Mr. Pegg was at Worcestershire Royal Hospital, those , who conducted the Trust’s serious treating him failed to apply the NICE guidelines which relate to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness. incident investigation into these events, told the inquest: “There was a policy in place for administering steroids, as per the 2020 NICE guidelines – this advises: (a) double dosing of oral steroids in cases of intercurrent illness until 48 hours after recovery ( also known as Sick Day rule 1 ); (b) if [ the patient has ] significant trauma, prolonged vomiting or diarrhoea, then 100mg IV hydrocortisone [ should be administered ]; 1 (c) if suspected adrenal crisis, 100mg IV hydrocortisone immediately.” In fact, the steroid treatment provided to Mr. Pegg during this admission fell far short of those Guidelines, in that: (a) He only received one double dose of his oral hydrocortisone medication, which he was usually required to take twice a day; (b) He received no doses at all ( double or standard ) of his oral prednisolone medication, which he was usually required to take once a day; (c) Although he did eventually receive a 100mg dose of IV hydrocortisone on 14.1.23, this should have been given much earlier that day when his condition seriously deteriorated. 2) Although in this case, I was unable to conclude that the above omissions in steroid treatment probably caused or contributed to Mr. Pegg’s death, it was nonetheless concerning to hear that none of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case. Unless action is taken to ensure clinicians employed by the Trust are aware of, and able to apply these Guidelines, there remains a risk that another patient with adrenal insufficiency may die in similar circumstances; 3) For a substantial part of his time at Worcestershire Royal Hospital, Mr. Pegg was being treated in a bed in a corridor in the Emergency Department, and then in the Majors Overflow area, both busy, crowded and noisy areas ill- suited to the proper treatment of patients. In his evidence to the inquest about trying to ensure that the Trust’s staff are aware of these Guidelines, Dr. Raven told the inquest: “As long as we still have crowded settings, it is difficult to provide assurances that these guidelines will be followed, for example because we have a high turnover of locum clinicians and agency nursing staff.” It is particularly concerning to hear that patients’ wellbeing may be put at risk because a hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines. It is perhaps unfair to put responsibility for rectifying this situation solely at the door of the Worcestershire Acute Hospitals NHS Trust, which is why this report is also being sent to NHS England and Health Education England. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of Worcestershire Acute Hospitals NHS Trust, and the National Medical Director of NHS England, 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 22 March 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: (a) , Mr. Pegg’s widow. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 26 January 2024 David REID HM Senior Coroner for Worcestershire 3
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.
David Donald William Reid
HM Senior Coroner
Worcestershire Coroner’s Court
The Civic, Martins Way
Stourport-on-Severn
Worcestershire
DY13 8UN
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
25 March 2024
Re: Regulation 28 Report to Prevent Future Deaths – Michael Leslie Pegg who
died on 15 January 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26
January 2024 concerning the death of Michael Leslie Pegg on 15 January 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Michael’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Michael’s
care have been listened to and reflected upon.
In your report you raised concerns that those treating Michael failed to follow National
Institute for Health and Care Excellence (NICE) guidelines relating to the treatment of
those with adrenal insufficiency conditions who are being treated for intercurrent
illness. NICE are responsible for producing these clinical guidelines and NHS Trusts
and bodies are expected to pay due regard to NICE and Royal College guidelines. As
you note in your Report, there is existing guidance on this issue from NICE. They are
also due to publish updated guidance on Adrenal insufficiency: acute and long-term
management later this year.
NHS England has also worked closely with the Society for Endocrinology and the
Royal College of Physicians on the issue of under-recognition and treatment of adrenal
insufficiency or crisis. This culminated in the publication of ‘Guidance for the
prevention and emergency management of adult patients with adrenal insufficiency’ in
July 2020, which outlines the causes of adrenal insufficiency, groups at risk of an
adrenal crisis, emergency management and management for surgical procedures. As
a result of work in this area, a new NHS Steroid Emergency Card was developed, to
be carried by patients at risk of adrenal crisis and ensure the prompt delivery of
steroids to those patients presenting within an emergency or acute medicine setting.
invasive procedures,
including day patients, should
The work above also resulted in the publication of the National Patient Safety Alert
(NatPSA), which includes the specific action that ‘Providers that treat patients with
acute physical illness or trauma, or who may require emergency or elective surgical or
their
other
admission/assessment/examination/clerking documentation to ensure it includes
prompts to check for risk of adrenal crisis and to establish if the patient has a Steroid
Emergency Card.’ Trusts were expected to implement actions around this specific alert
by 13 May 2021 and Worcestershire Acute Hospitals NHS Trust is recorded as being
compliant with this. We also note that it appears that the Trust has an internal guideline
on the management of adrenal insufficiency, published in March 2022. The Royal
College of Emergency Medicine (RCEM) has also issued professional guidance on
Addisonian Crisis.
review
Your Report also raised the concern that Michael received treatment in the Resus
Corridor and in the Major’s Overflow area and that the noisy and crowded conditions
put proper treatment of patients at risk. NHS England recognises that services across
the NHS are currently facing significant pressures. NHS England is committed to
improving patient experience within hospitals and in January 2023 we published a two-
year Delivery plan for recovering urgent and emergency care services. The plan aims
to relieve pressures on emergency departments by:
• Growing the workforce available for 111 online and urgent call services to offer
support, advice, diagnosis and referral.
• Expanding services within the community to prevent avoidable A&E admission.
This will include more joined-up urgent care within the community and use of
virtual wards.
• Helping people access the right care first time, ensuring that 111 is the first port
of call and reducing the need for people needing to go to A&E.
• Growing capacity and number of beds within hospitals to relieve pressures on
A&E Departments.
NHS England would refer you to the Trust on what actions are being taken locally to
address your concerns. We have been sighted on their Serious Investigation Report
and Action Plan and note that they have taken learnings around Emergency
Department crowding and improving end-of-life care for patients and are reviewing
staffing levels in the Overflow Area and Acuity.
I would also like to provide further assurances on 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 around preventable deaths are shared across the NHS at both
a national and regional level and helps us 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,
National Medical Director
Office of the Managing Director MD: Mr Stephen Collman 22 March 2024 Mr D D W Reid H M Senior Coroner Worcestershire Coroner’s Court Martins Way Stourport-on-Severn Worcestershire DY13 8UN Dear Mr Reid Re: Mr Michael Pegg deceased Regulation 28 Report to Prevent Future Deaths Thank you for forwarding on your Regulation 28 report. I have read your report with great care and note the concerns that you have raised as a result of the coronial inquiry into the death of Mr Michael Pegg. In your Regulation 28 report you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT) and I will respond to these concerns below, as a sequence, where appropriate. Concerns 1) The steroid treatment provided to Mr Pegg during this admission fell far short the guidelines. 2) None of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case. Unless action is taken to ensure clinicians employed by the Trust are aware of, and are able to apply these Guidelines, there remains a risk that another patient with adrenal insufficiency may die in similar circumstances. 3) Patient’s wellbeing may be put at risk because a Hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines The Trust has now implemented both further learning and additional checks, to ensure that steroid treatment provided to future patients will not fall short of the NICE Guidelines in the future. I have noted the actions taken below and I hope that they will ensure clinicians employed by the Trust are aware of, and are able to apply the relevant Guidelines in the future. • Steroid replacement therapy has been discussed in both the Trust Patient Safety Incident Response Group and the Deteriorating Patient, Resuscitation, End of Life and Mortality Group on Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD Office of the Managing Director several occasions since Mr Pegg’s sad death. Discussions included the importance of the adult patient document in the Emergency Department which was updated in June 2023. This now includes a time critical medications (highlighted steroid replacement) (please see appendix 1 attached). This is automatically included for all adults presenting to the Emergency Department. • A “detect and reflect” document and “time critical medication safety flash” have been circulated to all Emergency and Medical staff to raise awareness of the need for steroid replacement therapy (appendix 2, 3). These are displayed in the Emergency Department handover area. • Steroid replacement (and other time critical meds) has been highlighted in effective handover in ED in 2023 and will be repeated (appendix 4) to raise and maintain awareness for all medical staff working in the ED. • The Trust is due to move to an electronic patient record in the Emergency Department in Autumn 2024 – time critical medications including steroids are due to be incorporated into this. • The Emergency Departments on both sites are participating in a Royal College of Emergency Medicine audit looking at the prescribing and administration of time critical medicines, including steroids. This audit will provide a “benchmark” for the Trust and also highlight areas where further improvement is required. The audit is still in data collection phase but results will be available later in the year. • The Acting Chief Medical Officer will be attending the Induction for new doctors in August in order to highlight this area of focus for the Trust for all junior doctors rotating into our hospitals. • The Medical Examiners, at the request of the Trust, are working with Adrenal Insufficiency/Steroid Replacement as one of their high priority conditions which means that any concerns identified with steroid replacement will trigger further case review. The focus therefore remains on this area and will continue to be so until we are fully assured that our processes for identifying and managing this condition are effective. • The “overflow area” of the ED is no longer being used, having closed in October 2023. As a Trust, we have reflected on our practices as a result of Mr Pegg’s death. I hope the above demonstrates our commitment to ongoing learning and reassurance of our commitment to reinforce the NICE guidelines in relation to steroid treatment for patients. I trust that the foregoing has adequately addressed the Regulation 28 report issued subsequently to the inquest into the death of Mr Pegg. Should you require any further information in relation to this matter, please do not hesitate to ask. I confirm that I have not forwarded a copy of this response to any other Interested Person and would therefore be grateful if you could do so, as appropriate. Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD Office of the Managing Director I also confirm that the Trust is content for both the regulation 28 report and the response to be released or published should the Chief Coroner wish. Yours sincerely Managing Director Appendices 1. WEDAdult 2. Time Critical Medication Safety Flash v8 3. Detect and Reflect -WEB 207182 Addisonian Crisis. 4. Effective Handover June Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD
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