Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0366, written 9 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2024 |
|---|---|
| Reference | 2024-0366 |
| Deceased | Nancy Rogers |
| Coroner | Nicholas Shaw |
| Coroner area | Cumbria |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Morecambe Bay 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.
Kally Cheema LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
Tel: 0300 303 3180 | Email: hmcoroner@cumbria.gov.uk
Case Ref: 10350934
9 July 2024
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Hospitals Morecambe Bay Trust.
CORONER
Medical Director, University
I am Dr Nicholas Shaw HM Assistant Coroner for Cumbria
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 22 November 2023 I commenced an investigation into the death of Nancy ROGERS.
The investigation concluded at the end of the inquest . The conclusion of the inquest on
9th July 2024 was
Death from natural causes. The medical cause of death being
1a Bilateral Haemothorax
1b Ruptured Dissecting Aortic Aneurysm
1c
II
I also refer to an inquest opened on 10th August 2023 and concluded on
, the medical
23/11/23 touching on the death on 12th February 2023 of
cause of death being 1a Haemopericardium due to 1b Ruptured Dissecting Aortic
Aneurysm
CIRCUMSTANCES OF THE DEATH
1
2
3
4
18/11/2023- Nancy collapsed outside on Storey Square, Barrow when
she was walking with her sister
into town. This occurred around
1300hrs. An ambulance was called and Nancy attended A&E. She had
tests done however the results were not back and they are due to come
back on Monday 20/11/2023. Hospital discharged Nancy back to her
home address. They stated she possibly had fluid on her lung which
would need a referral. On 19/11/2023 at around 0530hrs
Nancy to the toilet; she left the bathroom to give Nancy some privacy
and immediately heard her fall.
Nancy was not breathing. CPR was started and the neighbour
went into the bathroom and
helped
came over as she heard the shouting through the wall. No
response to CPR from family attempts and paramedics arrived to
continue. Nancy is in the process of selling her home to return to the
Philippines and this has been causing her some stress.
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. –
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) At the inquest into Shirley Potter's death the hospital report indicated no learning was
required as her presentation was not typical. The circumstances in both these cases are
remarkably similar in that both ladies attended the emergency department at Furness
General and were allowed home only to die within a day of the same cause and as far as
the attending clinician at today's hearing knew no learning or teaching has taken place
since Nancy's death.
(2) As a coroner I am not permitted to suggest what actions might be taken but feel it
safe to mention NHS futures Aortic Dissection Toolkit and The Aortic Dissection
Charitable Trust for further information.
(3)
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and the
wider Trust have the power to take such action.
YOUR RESPONSE
5
6
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3rd September 2024. I, the coroner, may extend the period.
7
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
8
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
. I have also sent it to
,
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 July 2024
9
Signature
Dr Nicholas Shaw HM Assistant Coroner for
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.
INHS| University Hospitals of Morecambe Bay NHS Foundation Trust Trust Headquarters Westmorland General Hospital Burton Road Kendal LAQ 7RG Tel: 01539 732288 Web: www.uhmb.nhs.uk Your ref: Our ref: 3 September 2024 Dear Dr Shaw, Regulation 28 Report to Prevent Further Deaths Thank you for your report dated 9 July 2024. | am sorry that you have had cause to make a report, but we have carefully considered the concerns raised and | can now advise as follows. A meeting was held between the Clinical Lead - Emergency Medicine (FGH), the Clinical Lead - Emergency Medicine (RLI), the Clinical Lead - Urgent Treatment Centre WGH and the Deputy Medical Director (Education, Research, Workforce and Innovation) to discuss the cases of Shirley Potter and Nancy Rogers and another case that we had noted in the jurisdiction of the Senior Coroner Lancashire and Blackburn with Darwen. The discussion at the meeting centred on the best way to disseminate information regarding aortic dissection, in order to reduce the risk of this diagnosis being missed in the future. An action plan was written and since the meeting, the following actions have been put in place: e Contact has been made with the Aortic Dissection Charitable Trust and consent has been obtained to use their data and logos in any materials, teaching or discussions. e AnAé4 poster has been created (copy attached) and is displayed in the Emergency Department (ED) clinical areas and triage, for quick reference. The QR code links to a video on the Aortic Dissection Charitable Trust's website. e The video on the Aortic Dissection Charitable Trust website is being drawn to the attention of senior and junior medical staff at ED meetings at both of the Trust’s main hospitals, between July and the end of September. A list of the relevant staff has been compiled and new starters will be added. A tracker is being maintained of the dates when the video was viewed. A similar arrangement is also in place for nursing staff who perform triage. e Similar awareness raising is taking place at the Kendal Urgent Treatment Unit and the Same Day Emergency Care and Acute Medical Units. e Aortic dissection is now included in the new doctor induction in August. e A Standard Operating Procedure (SOP) for the management of Aortic Dissection is being created, to ensure a consistent approach to the management of aortic dissection throughout the Trust. This will be uploaded to Trust Procedural Documents library, which can be accessed from any Trust computer. There is currently a SOP in the medical guidelines and there are also regional guidelines. These are being combined for clarity and it is anticipated that this will be completed within the next 4-6 weeks. e An audit of the SOP has been included in the Audit Calendar. I hope this information is helpful but if you should require anything further, including a copy of the Action Plan, please do not hesitate to contact me. Yours sincerely, Chief Medical Officer Westmorland General Hospital Burton Road Kendal LAS 7RG CHAIR: PROFESSOR MIKE THOMAS Tel: 01539 732288 CHIEF EXECUTIVE: AARON CUMMINS
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