Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0479, written 24 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 | 24 Jul 2024 |
|---|---|
| Reference | 2024-0479 |
| Deceased | Regan Smith |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Suffolk and North Essex 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 Secretary of State for Department of Health & Social Care 1 CORONER I am Nigel PARSLEY, HM Senior Coroner for the coroner area of Suffolk 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 20 December 2023 I commenced an investigation into the death of Regan Edwin James SMITH aged 11. The investigation concluded at the end of the inquest on 23 July 2024. The conclusion of the inquest was that: Narrative Conclusion - Regan’s death was the result of an untreated natural cause, following a missed opportunity to provide medication which would have prevented his death from occurring. The medical cause of death was confirmed as: 1a Multiorgan Failure 1b Acute Liver Failure 1c Diabetic Ketoacidosis 4 CIRCUMSTANCES OF THE DEATH Regan Smith was declared deceased at the Kings College Hospital, Camberwell, in London on the 31st January 2023. On the 23rd January 2023 Regan had begun to breathe in a strange manner, so following a call to NHS 111 he was taken to the Accident and Emergency Department of the Ipswich Hospital. Once there Regan’s father spoke to a doctor who said he would only be checking for laryngitis, so his father took him home with a view to seeing a GP the next day. On the 24th January 2023 Regan was seen at his GP Surgery and laryngitis was diagnosed. On the 25th January 2023 Regan’s breathing changed rapidly, so an ambulance was called. A finger prick test was conducted by the ambulance crew showing Regan’s blood glucose level was much higher than it should have been. Regan was taken to the Accident and Emergency Department of the Ipswich Hospital, but the patient handover between the ambulance personnel and Accident and Emergency personnel was conducted in such a manner as to be ineffective. As a result, the earlier blood glucose test was not recorded on the Accident and Emergency records, and therefore not taken into consideration by treating clinicians at the Ipswich Hospital. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Due to Regan’s blood glucose level, he should have had further tests conducted, and it is more likely than not that he would have been immediately admitted, with treatment started to reduce his blood sugar level. However, in the absence of the initial blood glucose level result, no further glucose blood testing was undertaken, and Regan was discharged home with his father later that evening. On the 26th January 2023 Regan collapsed at home, and was taken initially to the Ipswich Hospital, but was transferred to Addenbrookes Hospital due to the seriousness of his condition. Regan had severe metabolic acidosis caused by previously undiagnosed diabetes. Once in the Paediatric Intensive Care Unit at Addenbrookes it was identified that Regan’s liver was beginning to fail, so he was transferred to a specialist unit at the Kings College Hospital in London. Once at the Kings College Hospital Regan’s condition continued to deteriorate until his sad death on the 31st January 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: (brief summary of matters of concern) The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023. Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians. Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover. The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case. It was heard that Regan’s verbal only handover occurred during a period of very high acuity. On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor. It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units. In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being handed over by ambulance personnel, and confirmed as being Regulation 28 – After Inquest Document Template Updated 30/07/2021 received by the receiving Accident and Emergency personnel. 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 18, 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 Chief Executive Officer East of England Ambulance Service NHS Trust Chief Executive Officer East Suffolk & North Essex NHS Trust Chief Executive Officer Cambridge University Hospital (Addenbrookes) NHS Trust Chief Executive Officer Kings College Hospital NHS Trust 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 Dated: 24/07/2024 Nigel PARSLEY HM Senior Coroner for Suffolk 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.
From Minister Karin Smyth MP
Minister of State for Health
39 Victoria Street
London
SW1H 0EU
18th September 2024
Our ref:
HM Coroner Nigel Parsley
Senior Coroner for Suffolk
Beacon House
Whitehouse Road
Ipswich
Suffolk
IP1 5PB
By email:
Dear Mr Parsley,
Thank you for your report of 24 July regarding the death of Regan Edwin James Smith. I am
replying as Minister with responsibility for urgent and emergency care.
Firstly, I would like to offer my sincere condolences to Mr Smith’s family and loved ones. It
is vital that where Regulation 28 reports raise matters of concern, these are looked at
carefully so that NHS care can be improved. I am grateful for you bringing these matters to
my attention.
Your report raises concerns with an ineffective handover of test results between the
ambulance service and the A&E staff at Ipswich Hospital, part of East Suffolk and North
Essex NHS Foundation Trust (ESNEFT), as well as emergency department pressures. In
preparing this response, Departmental officials have made enquiries with NHS England
(NHSE) and East of England Ambulance Service NHS Trust (EEAST).
Regarding the formal clinical handover of patients, there are a number of protocols that
should be followed. This includes standards set out by the General Medical Council on how
patient information should be shared, and the NHS standard contract which sets out targets
on handover delays. The responsibility for the implementation and oversight of protocols
across England is at a local level. I understand that ESNEFT submitted evidence during the
inquest which set out actions being taken locally to improve processes which you have
considered and were content with. EEAST advise that in the East of England, all hospital
A&Es have information systems to provide records of patients arriving by ambulance and
that they are ensuring that ambulance patient care records are available as part of the
assessment of patients who arrive at A&E by ambulance.
The rapid exchange of clinical information verbally remains an integral part of
communication. However, work is ongoing with NHSE to provide IT support that can deliver
improved sharing of electronic information across systems. Linking the ambulance computer
aided despatch system and electronic patient record collected by ambulance services with
emergency departments data will provide better information about the patient journey.
Further, to support learning and system improvement, an ambulance data set is also
currently being rolled out across England. This will be achieved by linking patient data
collected by ambulance services with data collected by emergency departments through the
emergency care data set.
Turning to the concerns your report rases in relation to the pressures in hospital emergency
departments. The Government accepts that urgent and emergency care services have been
below the high standards that patients should expect in recent years. The NHS has been
broken and it will take time to fix. However, we are determined to do so and have committed
to returning urgent and emergency care waiting times to the safe operational waiting time
standards set out in the NHS Constitution.
The Health Secretary ordered a full and independent investigation into NHS performance to
provide a frank assessment of the issues and challenges it faces. The investigation’s
findings, published on 12 September, 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, including by 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.
Thank you once again for bringing these concerns to my attention.
Yours sincerely,
KARIN SMYTH MP
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