Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0361, written 6 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2024 |
|---|---|
| Reference | 2024-0361 |
| Deceased | Paula Elsley |
| Coroner | Robert Simpson |
| Coroner area | Berkshire |
| 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 , Ringmead Medical Practice 1 CORONER I am Robert SIMPSON, Assistant Coroner for the coroner area of Berkshire 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 April 2022 I commenced an investigation into the death of Paula Elizabeth ELSLEY aged 54. The investigation concluded at the end of the inquest on 06 February 2024. The conclusion of the inquest was that: On the 28th March 2022 Paula Elizabeth Elsley died at her home address in Birch Hill, Bracknell. She was suffering from undiagnosed lung cancer with a metastatic tumour in her brain. This secondary tumour itself lead to the formation of an abscess which caused her death. 4 CIRCUMSTANCES OF THE DEATH On the 9th December 2021 Paula spoke to a GP on the phone reporting an ongoing cough. She had previously reported a shortness of breath in November 2021 which improved with antibiotics. She had also reported left leg pain and her leg giving way in the same month. Paula was not assesed further on this occasion and given worsening advice. On the 5th January 2022 Paula spoke to a GP reporting a new chest pain. She was not assessed further and given worsening advice. On the 17th February 2022 she spoke to another GP reporting back and leg pains. She was offered an assessment at the musculoskeletal clinic but declined. Paula had visited an osteopath on the 8th February and did so again on the 21st February. On the 25th February 2022 she reported to a GP that she had almost collapsed and that her legs had felt like jelly. The GP was concerned by these symptoms and booked her for a face to face assessment on the 1st March 2022. On the 4th March 2022 Paula attended the emergency department with left leg weakness, new left arm weakness and intermittent headaches. She was admitted for further investigations but decided to leave prior to these being completed. An outpatient MRI was arranged. On the 16th March 2022 she returned to the emergency department due to the severity of her headaches which were causing her to black out. She was not admitted on this occasion and was due to attend her MRI on the 27th March 2022. She did not make this scan due to circumstances beyond her control. Paula was found unresponsive at home on the 28th March 2022 and declared deceased. A Regulation 28 – After Inquest Document Template Updated 30/07/2021 post-mortem examination revealed a primary lung tumour with abscess formation and a brain abscess. The brain abscess was likely the result of a secondary brain tumour. 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) 1. Smoking status During the inquest I heard evidence that a patient's smoking status (current or former) was not routinely recorded by the GP practice in a manner that was immediately accessible when reviewing the medical records. I heard that it may be necessary to search through consultation notes and other records to discover this information and GPs do not necessarily have time to do so. A patient's current or former smoking status is relevant information for a GP considering whether a chest x-ray ought to be considered in line with NICE guideline entitled 'Suspected cancer: recognition and referral' (NG12). The GPs who gave evidence agreed that it would be helpful if this information was flagged and the GP practice has indicated that it intends to introduce such a system. However this is not yet in place and I am concerned that the risk of this information not being highlighted remains a current risk. 2. Thresholds for referral for a chest xray Based on evidence heard at inquest I am concerned that at the time of Paula's death (March 2022) the same NICE guideline was not being routinely considered by GPs. I was very pleased to hear that the practice subsequently introduced their own internal tool for considering if the threshold for a chest x-ray had been reached and that this has been discussed at GP and partner meetings. However some 22 months have now elapsed since Paula's death and no formal policy has been prepared. I remain concerned that the risk of the guideline not being considered remains whilst the change is procedure is informal, especially when it needs to be disseminated to new or locum GPs and other healthcare professionals such as nurses, paramedics and physician associates. 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 April 02, 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Frimley Health NHS Foundation Trust 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: 06/02/2024 Robert SIMPSON Assistant Coroner for Berkshire 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.
1st July 2024 Dear Sir I write to you regarding 'Regulation 28 report to prevent future death' that was issued following the inquest after the unfortunate death of Paula Elsley. I apologise profusely for the delay in sending my reply as we (in the practice) were not sure about the nature of reply that was required. Following the inquest we (all the partners) discussed in detail about the concerns expressed during the inquest. We discussed about easy visibility of the patient's smoking status which would be very useful during consultation. We considered the possibility of making the smoking status visible immediately when the patient's notes were opened but due to IT issues concerning more than 42000 patients that was thought not to be feasible but is easily visible when looking at care history. The issues were discussed in detail in partner's meeting and subsequent clinical meeting which is usually attended by all clinicians. We discussed about the need for checking and documenting smoking status and went through details regarding how to find it in the patient's notes easily (care history page). The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest Xray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms. We can definitely say that our Chest X ray requests have definitely: delete as repetition gone up which has also been helped by the Hospital Radiology being available over weekends. This information has also been circulated to Locum GPs as well. Hopefully the above measures will help us to reduce future preventable deaths in the practice. With regards GP Partner Ringmead Medical Practice Bracknell RG12 7WW
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