Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0401, written 25 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 | 25 Jul 2024 |
|---|---|
| Reference | 2024-0401 |
| Deceased | David Curry |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Norfolk and Norwich University Hospitals 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: The Secretary of State for Health and Social Care: The Department of Health and Social Care 1 CORONER I am Jacqueline LAKE, Senior Coroner for the coroner area of Norfolk 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 05 October 2023 I commenced an investigation into the death of David Alfred CURRY aged 77. The investigation concluded at the end of the inquest on 19 July 2024. The medical cause of death was: 1a) 1b) 1c) 1d) 2) Multi Organ Failure Urosepsis Ureteroscopy, Laser Lithotripsy and Insertion of Stent 20.09.2023 Ureteric stent insertion for urosepsis due to an obstructing ureteric stone 07.04.2023 Atrial Fibrillation, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease The conclusion of the inquest was: Mr Curry died from recognised risks of an appropriate procedure 4 CIRCUMSTANCES OF THE DEATH Mr Curry was admitted to Norfolk and Norwich University Hospital on 7 April 2023 when a stone was identified in the left lower ureter and a ureteric stent was placed as an emergency. Mr Curry was referred for a ureteroscopy which was undertaken on 20 September 2023 at Spire Norwich Hospital. Following the procedure Mr Curry showed signs of infection and was transferred to Norfolk and Norwich University Hospital where his condition deteriorated and he died on 1 October 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: 1. Mr Curry was treated for an infected obstructed left kidney and a left ureteric stent was placed as an emergency on 7 April 2023. Mr Curry's name was added to the NHS waiting list for Day Case urgent left ureteroscopy and laser stone fragmentation. Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. Mr Curry required timely management; coded as Priority (P) 2. P2 is used to denote the ideal time frame for performing surgery and in the event of this procedure, P2 timescale typically means within 4 weeks. 3. Evidence was heard that the risk of post operative urinary infection and sepsis is increased by prolonged stent dwell time. 4. Due to a lack of theatre capacity, Mr Curry did not receive a date for the proposed procedure at the NHS Trust and some five months following the initial procedure he approached Spire Norwich Hospital on 5 September 2023. The procedure was carried out on 15 September 2023. 5. Following the procedure being carried out Mr Curry developed sepsis and died on 1 October 2023. 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 19, 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 Norfolk and Norwich University Hospital Legal Team – Spire Counsel – Spire Healthcare Centre Legal Team – Spire Healthcare Centre Legal Team I have also sent it to: Department of Health Care Quality Commission HSSIB (Health Services Safety Investigations Body) Healthwatch Norfolk NHS England (NHS Improvement) 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: 25/07/2024 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH 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 Jacqueline Lake County Hall Martineau Lane Norwich NR1 2DH By email: Dear Jacqueline, From Minister Karin Smyth MP Minister of State for Health 39 Victoria Street London SW1H 0EU 13 September 2024 Thank you for the Regulation 28 report of 25 July sent to the Department of Health and Social Care about the death of Mr David Curry. I am replying as the Minister with responsibility for health, including secondary care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Curry’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the amount of time Mr Curry was on a waiting list for elective treatment – for five months from April 2023, until he approached a private provider in September 2023. Lack of theatre capacity at Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) is cited as the reason Mr Curry did not receive a procedure date. The report also raises concern about the increased clinical risks associated with Mr Curry’s long waiting time, particularly the increased risk of post operative infection which is cited as one of the medical causes of 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. It is unacceptable that some patients are waiting five months or more for elective treatment. The NHS and the Department are providing regional and national support and scrutiny to the most challenged Trusts with the largest backlogs of long waiters, including NNUH. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). NHSE has raised your concerns directly with the Integrated Care Board (ICB) relevant to this case (Norfolk and Waveney ICB). The ICB’s Elective Recovery Board (ERB) is responsible for overseeing elective activity in the area, supporting Trusts to maximise elective capacity, including theatre capacity, across the system, and to use capacity in line with clinical prioritisation. The ERB takes a system- wide approach to improving productive use of theatres and driving collaboration, including through mutual aid. In July, the Norfolk and Norwich University Hospital Orthopaedic Centre opened in NNUH, with four new theatres for elective orthopaedic surgery. Whilst Mr Curry’s surgery could not have taken place in this centre, the additional theatre capacity for orthopaedics will free up other theatres in the Trust for surgery in other specialties. With regards to your concern over the increased risks of long waiting times for elective treatment, the Trust has a Clinical Harm Review Group which oversees compliance with guidelines for monitoring and mitigating the risk of harm to people on waiting lists. The ICB has recently established a System Clinical Harms Review Group with an overarching aim of keeping people on elective waiting lists safe. The Group will bring together key partners to share learning and reduce unwarranted variation in clinical harm review processes across the ICS, including clinical prioritisation processes which would have impacted this case. The Group will also highlight to the ERB any themes emerging in terms of harms to be reviewed, so such harms can be mitigated for future patients. In future, the Group will expand and provide further ‘waiting well’ initiatives alongside the current harm review processes. Norfolk and Waveney ICB has reached out to the healthcare providers involved to offer their support to progress any internal learning identified. This case will be taken to their ICS Learning from Deaths Forum to ensure key learning is shared across the system. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, KARIN SMYTH MINISTER OF STATE FOR HEALTH
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