Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0470, written 27 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 | 27 Aug 2024 |
|---|---|
| Reference | 2024-0470 |
| Deceased | Dave Onawelo |
| Coroner | Graeme lrvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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.
MR G IRVINE
SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8ep
Telephone
Email
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (r)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Ref:2
1.
2.
Trust
Sent via email:
Care
Sent via email:
1
CORONER
, Ghief Executive Officer, Barts Health NHS Foundation
, Secretary of State for Dept. Health & Social
I am Graeme lrvine, senior coroner, for the coroner area of East London
2
CORONER'S LEGAL POWERS
I make this report under paragraphT, Schedule 5, of the Coroners and Justice Act 2009
and Regulations 28 and 29 of the coroners (lnvestigations) Regulations 2013.
http://www.leeislatio n.eov. u k/u kpea/2009/25lsched ule/5/pa raera ph/7
http://www. leeislation.eov. uk/u ksi/201-3/1629/pa rtl7/made
3
INVESTIGATION and INQUEST
On 30th December 2023 this court commenced an investigation into the death of Dave
Yola Anawelo, aged 34 years old. The investigation concluded at the end of the inquest
on 20th August 2024 when the court returned a narrative conclusion.
"Dave Yola Onawelo died in hospital on 30th December 2023. Dave suffered from sickle
cell anaemia, on the morning of 30th December 2023 he fett unwell and was assessed
by paramedics, he was advised to go to hospital but he dectined. Later that day, Dave
called a second ambulance and was transferred to
assessmenf
Whilst
1
Dave deteriorated and suffered an acute respiratory failure caused by an untreated
sickle cell crisis. Earlier interuention and treatment may have avoided a fatal outcome."
Mr Onawelo's medical cause of death was determined as;
1a Acute respiratory failure
1b Acute chest syndrome
1c Sickle celldisease
4
CIRCUMSTANCES OF THE DEATH
Mr Onawelo was 34 he was diagnosed with sickle cell anaemia.
On the morning of 30th December 2023 he felt unwell following a recent sickle cell crisis,
he rang 111 an ambulance was sent to his home at 11.56. On assessment a|12.40
Dave had a moderately fast breathing and heart rate and high blood pressure, his pain
was assessed as 6/10. Mr Onawelo was observed to have good oxygen saturation
levels and no temperature. Dave was advised to attend hospital, but he declined.
Later that afternoon Dave called for an ambulance due to a change in presentation, he
had developed difficulty in breathing. Clinical observations at 16.38 were unchanged, he
agreed to go to hospital.
At the local emergency department ("ED") a handover occurred at 17.23, at this time
Dave was not examined and no clinical observations or bloods were taken. A117.27,
Dave was assessed, he explained that he believed that he was in a sickle cell crisis,
partial observations were taken and he was deemed not to be acutely unwell and
therefore suitable for the lnitial Assessment ("14") section of the ED. He and his mother
were asked to remain in the waiting area.
Whilst waiting, Mrs Onawelo became concerned regarding her son's deterioration and
sought attention from hospital staff. A streamer told her that she was being anxious and
a senior nurse refused to assist telling Mrs Onawelo that she was "busy with 6 acute
patients". lt was only at '18.49 when Mrs Onawelo confronted medical and nursing staff
within the lA section that a nurse checked upon Dave. Mr Onawelo appeared drowsy
and was slouched to one side.
Dave was taken into the lA section in a wheelchair and observations were taken which
showed values consistent as those observed earlier, his chest was auscultated and
found to be clear. Whilst being cannulated a doctor noticed that Dave appeared unwell
and so made provision for him to be taken into a resuscitation bay. Dave then began to
experience seizures and sustained a cardiac arrest. A venous blood gas test
demonstrated that Dave was profoundly anaemic and acidotic, he had raised lactate and
potassium levels and a critically low blood sugar level.
Resuscitative efforts were commenced but discontinued at 19.48
5
CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. ln
my opinion there is a risk that future deaths could occur unless action is taken. ln the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows
A. Tlru Trusl. l'ällëü tu ädëquätëly lüëiltll'y ä ërltluälly lll pätlëilt wltlr ä pre-uxlstlrrg uu-
morbidity, sickle cell anaemia, that carried with it a hiqh risk of acute
2
eterioration. Earlier introduction of fluid resuscitation, blood
d
antibiotics is likely to have resulted in a non-fatal outcome. Factors in the
emergency department including, patient congestion, over-reliance on the
NEWS algorithm and a lack of compassion and clinical curiosity contributed to
the outcome.
and i/v
6
ACTION SHOULD BE TAKEN
ln my opinion action should be taken to prevent future deaths and I believe you
IAND/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 22"d October 2024lr, 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. othenivise, 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 lnterested
Persons the family of Mr onawelo, the care Quality commission and to the local
Director of Public Health 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 other 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 úseful
or of interest.
You may make representations to me, the coroner, at the
the release or the publication of your response.
ofyour response, about
I
IDATEI 27t08il2024 [StcNED By CORONER]
J
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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 22nd October 2024 Our ref: HM Coroner Graeme Irvine East London Coroner’s Court Queens Road Walthamstow London E17 8QP By email: Dear Mr Irvine, Thank you for the Regulation 28 report of 27th August 2024 sent to the Secretary of State about the death of Dave Yola Onawelo. I am replying as the Minister with responsibility for urgent and emergency care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Onawelo’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. In particular, your report raised concerns over patient congestion in the local emergency department, and the triaging and level of care provided. The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. You have raised the concerns about the care Mr Onawelo received directly with the responsible NHS body, the Barts Health NHS Foundation Trust. I understand the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia, and action to increase the number of nurses to help support increased patient demand in the emergency department. Turning to your concerns on patient congestion and the pressures on the NHS more generally. This government is committed to returning NHS services to the safe operational waiting time standards set out in the NHS Constitution. In doing so, we will be honest about the challenges facing the health service and serious about tackling them. As a first step, the Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future. In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance. This includes maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs. 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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