Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0314, written 10 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jun 2024 |
|---|---|
| Reference | 2024-0314 |
| Deceased | Margaret Pilgrim |
| Coroner | Sonia Hayes |
| Coroner area | Essex |
| 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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive Officer Princess Alexandra Hospital NHS Trust
1
CORONER
I am SONIA HAYES, area coroner, for the coroner area of ESSEX
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.
[HYPERLINKS]
3
INVESTIGATION and INQUEST
On 7 July 2023 I commenced an investigation into the death of Margaret Ann PILGRIM,
AGE 88. The investigation concluded at the end of the inquest on 5 June 2024. The
conclusion of the inquest was 1a Congestive Cardiac Failure and Bronchopneumonia,
2 Frailty, Fall with a Fractured Clavicle Natural Causes contributed to by a Fractured
Clavicle
4
CIRCUMSTANCES OF THE DEATH
Margaret Ann Pilgrim died of Congestive Cardiac Failure and Bronchopneumonia at the
Princess Alexandra Hospital on 29 June 2023 in a background of frailty. Mrs Pilgrim
sustained a fractured clavicle in an unwitnessed fall at home on 3 June 2023 and was
discharged from hospital on 4 June. Mrs Pilgrim’s fractured clavicle was not on her
discharge summary and her GP prescribed analgesia on 6 June. Mrs Pilgrim declined
rapidly on 10 June with delirium and again on 16 June and had been treated with
antibiotics. A scan on 19 June showed no evidence of pneumonia or malignancy and
Mrs Pilgrim remained unwell and further tests were completed. Mrs Pilgrim was admitted
into hospital and despite treatment continued to decline with intermittent delirium. Mrs
Pilgrim was placed on end-of-life care.
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 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. –
Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she
sustained a fractured clavicle that was reported on her X-Ray during her admission to
hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no
pain relief or consideration of care package
1
(2) The Discharge Summary omitted to inform the patient, her family or her GP of
the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family
with the Trust and the GP arranged analgesia, social care contact and follow-up
for the fracture clinic.
6
ACTION SHOULD BE TAKEN
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 5 AUGUST 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 Family of Mrs Pilgrim. I have also sent it to the Care Quality Commission 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.
9
10 JUNE 2024
HM Area Coroner for Essex
2
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.
Hamstel Road
Harlow
Essex
CM20 1QX
29th June 2024
Private and Confidential
Area Coroner Sonia Hayes
Essex Coroner’s Court
Chelmsford County Hall
Victoria Road
Chelmsford
CM1 1QH
Dear Coroner Hayes,
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
I write in the matter of the late Mrs Pilgrim in response to your recent Regulation 28 Report
to prevent future deaths which was issued on 11 June 2024.
Ms Pilgrim was admitted to Princess Alexandra Hospital on 3rd June 2023 at 20:45 following
a fall at home which resulted in her sustaining multiple grazes to her knees and elbows.
Whilst in the Emergency Department she underwent a CT of her head and an x-ray of their
right arm, shoulder and chest x-ray. These x-rays demonstrated a minimally displaced
fracture at the distal aspect of the right clavicle which was not noted at the time by the ED
team. The patient was deemed fit for discharge from a medical point of view and, following
review by the trust REACT (Rapid Emergency Assessment Care Team) was discharged the
following day.
Unfortunately, she was readmitted on the 22nd June 2023 with a community acquired
pneumonia and, despite ongoing care subsequently passed away on the 29th June 2023.
I note that three areas of concern which you have raised and will respond to in turn.
The Trust did not treat the patient for the fracture who was discharged with no
(1)
pain relief or consideration of care package
- The fracture was not identified prior to the patient being discharged, due to the minimal
displacement, which was reviewed by ED clinical team and not radiologist. Had the fracture
been identified and orthopaedic advice sought, they would have recommended the patient to
mobilise without restriction. No follow up would have been deemed necessary with this
fracture.
- Aside from when the patient was initially admitted there was no reference to the patient
complaining of pain in her shoulder by either the medical team or the therapists who
subsequently assessed her mobility (see next point). At the point of discharge no request for
analgesia was made by the patient or her daughter.
- The patient was advised to stay in the ED overnight in order to be seen by the REACT
(Rapid Emergency Assessment Care Team) prior to her discharge so that she could be
assessed for a potential package of care. Their assessment was that at the time she did not
meet the threshold for this however some additional equipment was provided and ordered
for her.
The Discharge Summary omitted to inform the patient, her family or her GP of
(2)
the fracture and no follow-up in the fracture clinic was booked
- The discharge summary did not reference the fracture as this was not identified at the time
of the patient’s attendance to the ED.
- Had the fracture been identified follow up in fracture clinic would not have been required as
conservative management would have been recommended
The fracture was only confirmed when the GP raised the concerns of the family
(3)
with the Trust and the GP arranged analgesia, social care contact and follow-up for
the fracture clinic.
- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence
there is a process in place by which the reported images are subsequently reviewed by an
ED consultant. Unfortunately, in this instance the report was filed without the patient or GP
being informed. We have discussed this incident with the department and reviewed this
process to assure ourselves that it is as robust a process as possible and in line with other
EDs nationally. One contributing factor to the human error that occurred was noted to be our
IT systems which requires our clinicians to work with multiple different programmes in order
to review the images and patient notes. I would like to reassure that we are due to launch a
comprehensive Electronic Health Record in November of this year which we are confident
will resolve this issue and reduce the likelihood of recurrence.
I hope this letter helps address the concerns raised in your Regulation 28 notice for
prevention of future deaths.
Please do not hesitate to contact me if you require any further details.
Yours sincerely
Medical Director
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