Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0513, written 25 Sep 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 Sep 2024 |
|---|---|
| Reference | 2024-0513 |
| Deceased | Jyoti Rao |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care 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: Foundation Trust CORONER , Chief Executive Officer, Manchester University NHS I am Chris Morris, Area Coroner for Greater Manchester (South). 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 19th June 2024, Alison Mutch, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Jyoti Rao, who died on 20th February 2024 at Tameside General Hospital, Ashton- under-Lyne, aged 56 years. The investigation concluded with an inquest which I heard on 16th September 2024. The inquest determined that Miss Rao died as a consequence of:- 1) a) Hypoxic-ischaemic brain injury; b) Sepsis on background of end-stage renal failure with failure of transplanted kidney. II Traumatic nasogastric tube insertion The conclusion of the inquest was a Narrative Conclusion, to the effect that Miss Rao died as a consequence of complications arising from renal transplantation. CIRCUMSTANCES OF THE DEATH Miss Rao died on the 20th February 2024 at Tameside General Hospital, Ashton-under-Lyne as a consequence of Hypoxic-ischaemic brain injury due to sepsis on the background of end-stage renal failure with failure of a transplanted kidney. Miss Rao’s death was contributed to by traumatic nasogastric tube insertion. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Whilst the court heard evidence as to the advantages of the ‘Consultant of the Week’ model in terms of team working, it is a matter of concern that complex transplant patients such as Miss Rao are not allocated a named consultant, who not only (in conjunction with others) can seek to ensure continuity of care is provided, but also who can take a longer-term view of the patient’s post- operative course and trajectory when complications arise. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th November 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 I have sent a copy of my report to the Chief Coroner, Miss Rao’s brother and sister-in-law, and the Trust’s legal team. I have also sent a copy to Tameside and Glossop Integrated Care NHS Foundation Trust, the Care Quality Commission and NHS Greater Manchester Integrated Care 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. Dated: 25th September 2024 Signature: Chris Morris, Area Coroner, Manchester South.
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.
Joint Chief Medical Officers’ Office Trust Headquarters Room 218, Cobbett House Oxford Road M13 9WL 20 November 2024 Mr C Morris HM Area Coroner Manchester South Coroner’s Office 1 Mount Tabor Street Stockport SK1 3AG Sent via email only: Dear Mr Morris Miss Jyoti RAO – Regulation 28: Prevention of Future Deaths Thank you for your Regulation 29 Report to Prevent Future Deaths dated 25 September 2024 addressed to Mr Mark Cubbon in his capacity as Trust Chief Executive of Manchester University NHS Foundation Trust (MFT) following the Inquest into the death of Miss Jyoti Rao which you heard on 16 September 2024. I have now had the opportunity to acknowledge and consider the matters of concern that were raised within your report and which emerged during the inquest of Miss Rao. On behalf of the Trust, I would like to extend my sincere condolences to the family of Miss Rao for their very great loss. The response required from the Trust) is in relation to the following: • Under the current Consultant of the Week model, complex transplant patients are not allocated a named consultant, who not only (in conjunction with others) can seek to ensure continuity of care is provided but also who can take a longer term view of the patient’s post-operative course and trajectory when complications arise MFT comprises several adult hospital sites within which Consultant of the Week models are utilised. Organisationally the Trust provides clear guidance to clinical teams via the Role and Responsibilities of the Lead (Responsible) Consultant Policy (attached) and there is an organisational focus on consultant attribution. Whilst the remit of this improvement work is wider than the specialty transplant service subject of your Regulation 28 report; I hope to offer you additional assurance that across the organisation discussions in relation to consultant attribution, ownership and oversight of care are taking place across all clinical teams. I anticipate that this work will continue to strengthen the delivery of care to our patients utilising this model, preventing inconsistencies in practices across the organisation. Specialties at Manchester Royal Infirmary (MRI), alongside the other hospitals within MFT and nationally, adopt the Consultant of the Week model which is widely recognised as being an advantageous care delivery model for patients admitted to hospital. Your concern in respect of how this model adequately supports complex transplant patients is however recognised. As the Inquest heard, and you referenced within your letter, there are advantages of this model with the presence of a consultant of the week being associated with reducing length of stay and improving continuity and communication. For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant. I acknowledge that whilst the Inquest heard about this process, there was a lack of evidence provided to the hearing demonstrating how these arrangements robustly account for the more complex transplant patient, particularly those receiving outpatient care. Since the Inquest, I can confirm that actions have been taken to strengthen this process, which I have explained below. The MRI Transplant team have modified the weekly Wednesday Ward Patient Review meeting, mentioned above, to make it an MDT for discussion of complex patients. This provides a more robust multidisciplinary perspective with decision making that involves all relevant clinical staff. A significant change is the attendance of the outpatient team to support any issues on discharge. In addition to this, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting. Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues raised. If you require anything further, then please do not hesitate to contact me. Yours sincerely Joint Chief Medical Officer / Responsible Officer Encl. Role & Responsibilities of the Lead (Responsible) Consultant Policy Examples of possible lead/attending consultant models for Provider Care teams www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
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