Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0347, written 27 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 | 27 Jun 2024 |
|---|---|
| Reference | 2024-0347 |
| Deceased | John Parry |
| Coroner | Catherine Mason |
| Coroner area | Leicester City and South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: University Hospitals of Leicester NHS Trust 1 CORONER I am Professor C E MASON, His Majesty's Senior Coroner for the coroner area of Leicester City and South Leicestershire. 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 16 November 2023 I commenced an investigation into the death of John Kenneth PARRY aged 72. The investigation concluded at the end of the inquest on 26 June 2024. The conclusion of the inquest was that: Following the falls on the 6th July 2023 Mr Parry was commenced on neurological observations. However, they were not carried out in accordance with the hospital trust policy. In addition, the calculations were inaccurate. As a result, no reliance could be placed on the observation recordings. Medical evidence also makes it clear that Mr Parry should have had a CT head scan within one hour of his fall. Had this been carried out, on a balance of probabilities, the intracranial bleed could have been detected sooner and there would have been a chance of reducing the mortality risk and achieving a better outcome. The cause of death was established as: I a Spontaneous Intracerebral Haemorrhage I b I c II Mitral Valve Disease (On Anticoagulation) 4 CIRCUMSTANCES OF THE DEATH John Parry was a 72-year-old male who was admitted to the Leicester Royal Infirmary via the Emergency Department on the 4th July 2023. He presented with feeling unwell for six weeks, a headache for one month, weight loss and an increased urinary frequency for a few days prior to admission. He was appropriately investigated but no conclusive diagnosis was made regarding the Regulation 28 – After Inquest Document Template Updated 16/05/2023 cause. On the 6th July 2023 Mr Parry had two unwitnessed falls. Later that day his condition deteriorated and following a CT scan of his head a spontaneous bleed was diagnosed. In consultation with the neurosurgeons at the Queens Medical Centre, Nottingham it was decided that Mr Parry was not suitable for surgical intervention and the decision was made to commence Mr Parry on palliative care. He died on the 7th July 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) The evidence heard raised a concern about the safe prescribing of warfarin. When a doctor is asked by a nurse to dose the warfarin, the accepted practice is that the doctor relies on the nurse to give all relevant information and the doctor only checks the INR blood results from the laboratory. There is no requirement or expectation that the doctor looks at the patient’s medical records or seeks information about the patient. At the inquest evidence was heard that the nurse had not communicated all relevant information. Although in this case it did not have an adverse outcome, it was accepted that there was a risk that if a doctor does not have all relevant information, warfarin could be prescribed and administered and there could be a risk of death. Evidence was given that this lack of appropriate communication was believed to be unusual but it was accepted that it is not necessarily known how unusual because it would probably only become apparent in cases of an adverse outcome. 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 August 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: Browne Jacobson Solicitors (representing the hospital trust) I have also sent it to: NHS England Regulation 28 – After Inquest Document Template Updated 16/05/2023 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: 27/06/2024 Professor C E MASON His Majesty's Senior Coroner for Leicester City and South Leicestershire Regulation 28 – After Inquest Document Template Updated 16/05/2023
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.
University Hospitals of Leicester Headquarters Level 3 Balmoral, Leicester Royal Infirmary Infirmary Square Leicester LE1 5WW Prof. Catherine Mason Senior Coroner for Leicester City The Coroner's Court, Town Hall Town Hall Square Leicester LE1 9BG 21 Aug 2024 Dear Professor Mason Thank you for your Regulation 28 Report dated 27th June 2024, which arose out of your inquest into the death of Mr John Parry. Whilst it was acknowledged that it did not have an adverse outcome, you were understandably concerned about the potential impact on patients which might result from ineffective communication among the treating clinical team. We fully accept and recognise the paramount importance of communication between all members of the multidisciplinary team in ensuring safe and effective patient care. Following on from the issues raised in your Regulation 28 Report we have re-emphasised the importance of clear and effective communication between all colleagues in particular regarding anticoagulation. This includes sharing learning from this case with all ward leaders, matrons and through our chief nurse forums. A reminder to all clinical teams via the daily brief of the importance of giving clear information was included in the week commencing 29/07/24 and was repeated in the week commencing 05/08/24. The daily brief has three key messages and is read out to all clinical teams at every huddle every day for a week. We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-into another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system. To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes. I trust that this gives you assurance that we take this matter very seriously as we look to strengthen our processes and make them more robust. If you wish for any further information, please do not hesitate to contact me. Yours sincerely, University Hospitals of Leicester NHS Trust and University Hospitals of Northamptonshire NHS Group Chief Executive
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