Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0400, written 18 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 | 18 Jul 2024 |
|---|---|
| Reference | 2024-0400 |
| Deceased | Noura Hardy |
| Coroner | Gareth Jones |
| Coroner area | West Sussex, Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Sussex 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.
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 1 CORONER I am Gareth JONES, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 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 21 March 2023 I commenced an investigation into the death of Noura HARDY aged 73. The investigation concluded at the end of the inquest on 18 June 2024. The conclusion of the inquest was that: Noura Hardy died on the 14th of March 2023 at Royal Sussex County Hospital in Brighton of a cardiac arrest following a septal ablation procedure complicated by perforation of a coronary artery. 4 CIRCUMSTANCES OF THE DEATH Ms. Hardy suffered from severe left ventricular hypertrophy. She was admitted to hospital in March 2023 for a septal ablation procedure. Her coronary artery was perforated before the procedure. She subsequently died of a cardiac arrest. 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) 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: In addition to her heart difficulties, Ms. Hardy had taken steroids for a long period of time for temporal arteritis. She was put on a waiting list for her heart treatment in June 2022 but not treated until March 2023, nine months later. The evidence of the Cardiac Surgeon who gave evidence at the Inquest was that the long term steroid use significantly weakened her heart muscles such that she suffered a perforation which subsequently led to her death. If she had been treated earlier, the muscles may not have been weakened to such an extent that she died. The local Trust (UHS Foundation Trust) Regulation 28 – After Inquest Document Template Updated 30/07/2021 assures me that waiting lists for heart treatment are now between 9 and 22 weeks which is reassuring. However I am still concerned about waiting lists for heart treatment being too long and consider this a national problem. Excessive waiting lists for heart treatment can be fatal. 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 September 12, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons University Hospitals Sussex NHS Foundation Trust 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: 18/07/2024 Gareth JONES Assistant Coroner for West Sussex, Brighton and Hove 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.
Our ref: HM Coroner Gareth Jones Record Office Orchard Street Chichester PO19 1DD By email: Dear Gareth, From Minister of State for Health 39 Victoria Street London SW1H 0EU 12 September 2024 Thank you for the Regulation 28 report of 18 July sent to the Department of Health and Social Care about the death of Ms Noura Hardy. I am replying as the Minister of State for Health with responsibility for elective care. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Hardy’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the length of time Ms Hardy was on a waiting list for heart treatment - for nine months from June 2022 until her untimely death in March 2023. Clinical evidence given at the inquest states that the long term interim steroid use, whilst on the waiting list, significantly weakened Ms Hardy’s heart muscles such that she suffered a perforation which subsequently led to her death. I want to assure you that tackling waiting lists is a key part of our Health Mission and a top priority for this government, as we get the NHS back on its feet. We have committed to achieving the NHS Constitutional standard that 92% of patients should wait no longer than 18 weeks from Referral to Treatment (RTT), by the end of this parliament. We recognise that it is unacceptable that some patients are waiting 9 months for definitive cardiology treatment. The NHS and Department are providing additional regional and national support and scrutiny to the most challenged trusts with the largest backlogs of long waiters and will continue to work towards the target in NHSE’s 24/25 planning guidance to eliminate waits of over 65 weeks by September 2024. Furthermore, this government is committed to change the NHS so that it becomes not just a sickness service, but able to prevent ill health in the first place. A focus will be on ensuring fewer lives are lost to the biggest killers and reducing deaths from heart disease and stroke by a quarter within ten years. In preparing this response, Departmental officials made enquiries with NHS England (NHSE) in order to gain a more detailed response at local level and received the below information: With regard to reviewing the long-term use of steroids, University Hospitals Sussex NHS Foundation Trust confirmed that the patient was noted to be significantly breathless and had steroid-dependent arteritis, and reviews were part of her ongoing care and treatment for her conditions. The consultant explained in his evidence that cardiology waiting times were longer due to the hangover effect of covid, and that Ms. Hardy suffered a complication which would happen regardless of the waiting list times. Waiting time information on the NHS My Planned Care website states the current waiting times are: - First outpatient appointment – 24 weeks. - Waiting time for treatment (outpatient or inpatient) – 23 weeks. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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