Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0437, written 8 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Aug 2024 |
|---|---|
| Reference | 2024-0437 |
| Deceased | Mary Horgan |
| Coroner | Adrian Farrow |
| Coroner area | Greater Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University NHS Foundation Trust · Northern Care Alliance 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 THIS REPORT IS BEING SENT TO: The Chief Executive, Northern Care Alliance NHS Foundation Trust, Mayo Building, Salford Royal, Stott Lane, Salford, M6 8HD 1 CORONER I am Adrian Farrow, assistant coroner, for the coroner area of Greater Manchester South 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 13th June 2023 an investigation was commenced into the death of Mary Margaret Horgan, aged 80 years. The investigation concluded at the end of the inquest on 6th August 2024. The inquest found that the medical cause of Mrs Horgan’s death was: 1a) Severe Compressive Spinal Cord Injury 1b) Traumatic Cervical Spinal Injury with Fracture Dislocation of the Cervical Spine. The conclusion of the inquest was that she died from complications arising from a significant spinal injury sustained in an accidental fall. 4 CIRCUMSTANCES OF THE DEATH Mrs Horgan fell at home on 5th May 2023. She was taken by ambulance to Wythenshawe hospital where a CT scan revealed no evidence of trauma to her neck or spine. However, she continued to experience pain to her neck and an MRI scan was attempted on 8th May to investigate further. Unfortunately, Mrs Horgan was unable to tolerate the procedure due to claustrophobia and anxiety on a background of bipolar affective disorder. No further attempt was made thereafter to mobilise Mrs Horgan, pending the MRI scan. By 11th May 2023, there were indications of spinal cord compromise, but these were subtle signs for which there were other possible credible alternative causes and the CT scan had shown no bony trauma. Although the plan was to continue to attempt to undertake an MRI scan, with sedation if necessary, due to pressures on the scanning equipment, no slot became available over the coming days. By 14th May, Mrs Horgan’s breathing had become laboured, with hindsight, indicating a progression of spinal cord compression. The MRI scan was successfully achieved on 15th May. The radiological report failed to identify a dislocated fracture at C5/6 with spinal cord compression. In the light of the misleading report of the MRI scan, and weakness noted in Mrs Horgan’s left arm, a referral was made via Patient Pass to the spinal team at Salford Royal Hospital at 19.10 hours. The Patient Pass system notified the on-call Registrar at the spinal unit of the new referral by text message and the Registrar triaged the referral, replying via Patient Pass to Wythenshawe hospital at 19.44 hours. Two minutes later, the Registrar contacted the on-call spinal Consultant. The evidence was that there is no alert generated by Patient Pass to the referrer to indicate that a reply has been generated. The spinal Consultant accessed the referral and the radiological scans, immediately identifying the C5/6 dislocated fracture and significant compromise of the spinal cord. By 20.36, there had been no response from Wythenshawe Hospital and the spinal 1 Consultant posted another message on Patient Pass raising a number of questions seeking background information, highlighting the seriousness of Mrs Horgan’s condition and advising that she be transferred as soon as possible to Salford Royal Hospital with and Aspen collar and spinal precautions. Further attempts by the on-call Registrar at Salford Royal Hospital to gain information from Wythenshawe Hospital by telephone were unsuccessful, in all likelihood because of a recent change of shift on the ward. Arrangements were made by the Wythenshawe Night Manager and the Salford Bed managers to transfer Mrs Horgan to Salford Royal by ambulance, but no collar or spinal precautions were deployed. By the time of the transfer, Patient Pass had not been accessed by the medical staff at Wythenshawe Hospital. The Patient Pass system was next checked at around 22.30 hours, by which time, Mrs Horgan had been taken to Salford Royal Hospital. The inquest heard that Patient Pass can only be accessed by medical staff with a General Medical Council registration number. The inquest also heard that the spinal unit at Salford Royal Hospital usually respond to new referrals within 30-40 minutes and in any event, a response can certainly be expected within an hour of the referral. The spinal unit regard all referrals via Patient Pass as urgent, hence the speed of the triage and initial response times. By contrast, the understanding of the medical staff at Wythenshawe is that Patient Pass is the only and routine method of referral for in- patients and there is no mechanism to indicate the receipt of a response or, if necessary, to differentiate between urgent and non-urgent referrals. On the part of the spinal unit at Salford Royal Hospital, from the evidence, it is anticipated that referrers would anticipate the swift response to a new referral, whereas there was no corresponding anticipation on the part of the medical staff at Wythenshawe Hospital of a need to expect a response within that timescale. Identifying and reading a response requires the referrer regularly to log in to Patient Pass to look for a response. The inquest heard that it may be possible for staff such as bed managers to obtain some information from the Patient Pass system, it was not directly accessible to them. The inquest also heard that it is possible to make bespoke amendments to the Patient Pass operations so as, for example, to give additional information about anticipated response times and contact numbers. It was also clear from the evidence that Patient Pass is widely used by a number of specialty units, whose working practices and utilisation of the Patient Pass system may differ. The inquest also heard that there is no specific induction training for junior doctors nor any refresher training for established doctors relating to the Patient Pass system within the established training programs. Once Mrs Horgan arrived at Salford Royal Hospital, it was clear that she was quadriplegic and that there was severe spinal compression. A further CT scan confirmed the dislocated C5/6 fracture. She was admitted to the Critical Care Unit. It was necessary to address low blood pressure in particular and having regard to her frailty and the poor response to blood pressure support, the decision was made, with Mrs Horgan and her family, that the risks outweighed any potential benefit of spinal surgery and palliative care was adopted. She was placed on end of life care and died on 5th June 2023. 5 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 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. – Whist the inquest found, on the evidence, that the transfer of Mrs Horgan between hospitals without an Aspen collar and spinal precautions as advised did not significantly contribute to her death, the obvious disparity revealed by the evidence between the two medical teams of their respective understanding and expectations of the way in which Patient Pass operates serves to create uncertainty and confusion and could easily give rise to a situation where the lives of patients may be put at risk. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 3rd October 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 , on behalf of Mrs Horgan’s family and the Chief Executive, Manchester University NHS Foundation Trust, Cobbett House, Oxford Road, Manchester, M13 9WL. I have also sent a copy of my report to the Chair of the Greater Manchester Integrated Care Partnership, 4th Floor, 3 Piccadilly Place, Manchester M1 3BN and The Directors, Patient Pass Limited, Tomorrow Building, Media City UK, Salford, Greater Manchester, M50 2AB 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 Adrian Farrow Hm Assistant Coroner 08.08.2024 3 4
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.
Mr Adrian Farrow HM Assistant Coroner for Greater Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 3 October 2024 Dear Mr Farrow Re: Inquest into the death of Mrs Mary Horgan I write regarding the inquest into the death of Mrs Mary Margaret Horgan which concluded on 6 August 2024 in which you issued a Regulation 28 report to Prevent Future Deaths. Mrs Horgan sadly died following an admission to Salford Royal Hospital, responsibility of the Northern Care Alliance NHS Foundation Trust (“The Trust”), following transfer from Wythenshawe Hospital, responsibility of Manchester University NHS Foundation Trust (“MFT”). May I take this opportunity to express my sincere condolences to the family of Mrs Horgan. Thank you for bringing the concerns raised in the Regulation 28 report to my attention. Your concerns were as follows: “Whilst the inquest found, on the evidence, that the transfer of Mrs Horgan between hospitals without an Aspen collar and spinal precautions as advised did not significantly contribute to her death, the obvious disparity revealed by the evidence between the two medical teams of their respective understanding and expectations of the way in which Patient Pass operates serves to create uncertainty and confusion and could easily give rise to a situation where the lives of patients may be put at risk.” The Trust is always open to the opportunity to review, and where possible, strengthen our processes. I hope the below offers assurance to both you and Mrs Horgan’s family that the Trust has continued to take these concerns seriously and has put in a number of steps and actions since the tragic death of Mrs Horgan. Communication across GM sites regarding the operation of Patient Pass Patient Pass is a web-based tertiary referral platform which facilitates referrals from hospital-based services to a selection of tertiary services hosted by the Trust and allows for real-time two-way communication between the referrer and the tertiary service. 1000673431.1 Patient Pass is used in a number of services and was introduced as an alternative to telephone-based urgent referrals to the specialist on-call teams. Patient Pass provides a single, auditable record of referrals and advice given, which is accessible to teams at the referring organisation and the tertiary service. The Trust acknowledges that there was sub-optimal communication between Salford Royal Hospital and Wythenshawe Hospital regarding Mrs Horgan’s referral to the spinal team, resulting in her being transferred without spinal precautions. , Consultant Vascular Radiologist The Trust has convened a working group, including and lead for Quality and Patient Safety from MFT to discuss how we can improve and strengthen communication between the Trusts, and to gain input and perspective from MFT as an external referrer. This group has reviewed this incident, and agreed a number of actions to both improve understanding of the Patient Pass system and improve the system itself to reduce the likelihood of recurrence of such an incident. As a result, we have prepared a communications guide, which outlines the purpose of Patient Pass and clarifies the responsibilities of referrers and receivers. This document is due to be finalised shortly and will be circulated across Greater Manchester hospitals via their Medical Directors. The guide informs the referrer that telephone contact details must be included at the time the referral is made, which will ensure that the specialist team can make timely contact by phone, if required, to provide time-critical advice. The Patient Pass system itself will also be updated to make the inclusion of a telephone number a mandatory field. Any non-urgent advice will continue to be provided via the Patient Pass system, so the guide also advises the referrer that Patient Pass should be accessed regularly for on-going communication with the tertiary service. The tertiary services are also required to attempt to contact the referring service via telephone when there is time critical action required by the referrer, supplemented by appropriate documentation in Patient Pass. In addition to this, there are expectations on referrers and the tertiary service at an organisational level to ensure that potential users of Patient Pass are aware of how to use the system and the obligations on the user through their induction processes. The system will be audited regularly to ensure adherence to the referral guidelines, with feedback being issued to the referring Trust as required. Changes to Patient Pass In order to assist with improving the operation of Patient Pass, the Trust is collaborating with the Patient Pass developers to make changes to the system as follows: Telephone number field is to be mandatory, with wording included such as, “Please enter a telephone number that can be contacted 24/7 to receive urgent information about the patient being referred. This number must not be a general switchboard number and should be updated as required”. 1000673431.1 A mandatory box for the referrer to confirm the case has been discussed with a Consultant prior to referral. Including a screen when a new user registers to use Patient Pass outlining their responsibilities, of which users need to confirm acceptance before proceeding to use the system. Letter of concern I am grateful to you for alerting me to your concerns regarding the management of transferring patients between the Trusts in your letter dated 8 August 2024. Discussions have taken place with MFT colleagues and both Trust’s transfer policies have been reviewed and considered in light of Mrs Horgan’s case. Both policies were appropriate, consistent and in date at the time of the incident, however, regrettably the principles within them were not fully applied. In line with a request from the Greater Manchester Integrated Care Board, the Trusts are creating a seven-minute briefing document to share learning across Greater Manchester regarding the need to fully apply our transfer policies and to highlight the learning around the use of the Patient Pass system. We will consult with Dr Dare Seriki to prepare and circulate this in October 2024. I hope the above offers you reassurance of the Trust’s ongoing commitment to managing patient safety risks and to continually improve the care and services we provide. Please do not hesitate to contact me if you require any further information in relation to our response. Yours sincerely Chief Executive 1000673431.1
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