Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0525, written 3 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Oct 2024 |
|---|---|
| Reference | 2024-0525 |
| Deceased | John Turner |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: Care CORONER I am Chris Morris, Area Coroner for Manchester South. CORONER’S LEGAL POWERS , Secretary of State for Health and Social 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 7th June 2024, I opened an inquest into the death of John Turner who died on 23rd August 2023 at Tameside General Hospital, Ashton-under-Lyne, aged 73 years. The investigation concluded with the inquest which I heard on 27th September 2024. A post mortem examination determined Mr Turner died as a consequence of: 1) a) Pulmonary Embolism; 1) b) Deep Vein Thrombosis. At the end of the inquest, I recorded a conclusion of Natural Causes contributed to by Neglect. CIRCUMSTANCES OF THE DEATH Mr Turner died on 23rd August 2023 at Tameside General Hospital as a consequence of a Pulmonary Embolism due to a Deep Vein Thrombosis, neither of which had been identified when he previously presented at the hospital's Emergency Department on 20th August 2023. Mr Turner first became unwell whilst on holiday in Greece and experienced a cough and following his return home, progressive breathlessness. A course of oral antibiotics prescribed by a staff member at the GP surgery did nothing to improve his symptoms, leading Mr Turner to attend the Emergency Department where he was assessed and sent home without any further treatment in circumstances where a D-Dimer test requested by the triage nurse was not undertaken 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 court heard evidence as to a wide-range of factors ranging from demographics, difficulties in accessing primary care and increasing acuity of illness in an ageing population which have combined to create great pressure on hospital Emergency Departments. In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs. In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record, in all likelihood reflecting competing clinical demands on her time. In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced. 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 28th 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 and Turner’s family, together with s of Weightmans LLP on behalf of the Trust. of Leigh Day & Co. on behalf of Mr I have also sent a copy to the Care Quality Commission, Tameside Metropolitan Borough Council, NHS Greater Manchester Integrated Care Partnership and Parliament for Ashton-under-Lyne, who may find it useful or of interest. , Member of 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: 3rd October 2024 Signature: Chris Morris HM 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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 28th November 2024 Our ref: Chris Morris Area Coroner for Greater Manchester South. His Majesty’s Coroner’s Office, 1 Mount Tabor Street, Stockport SK1 3AG By email: Dear Mr Morris, Thank you for the Regulation 28 report of 3rd October 2024 sent to the Secretary of State about the death of John Turner. 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 Turner’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. The report raises concerns regarding poor patient flow and delays to patient care due to competing clinical demands, particularly during times of high demand at Tameside and Glossop Integrated Care NHS Foundation Trust (TGHT). I recognise the concerns raised with health and care delivery in the region, which align with representations from local Members of Parliament. In preparing this response, my officials have made enquiries with the Care and Quality Commission and NHS England to ensure we adequately address your concerns. Patient flow is a significant issue facing hospitals across the country which can lead to unacceptable delays for patients. I am assured by NHS England that every patient at TGHT is triaged and prioritised based on their clinical presentation. I am informed that Mr Turner was triaged as a category 2 (to be seen by a clinician within 120 minutes) and was seen at 3 hours 13 minutes post triage due to the pressures in the emergency department on that day. I understand that TGHT has recently opened the rebuilt emergency department, which now has a larger footprint and the capacity to see more patients simultaneously. This is expected to improve waiting areas and reduce waiting times for patients. At a national level, this government is committed to returning 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. 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. The plan's reforms will support a reduction in the demand pressures on the health service through three shifts to ensure the health service can tackle the problems of today and tomorrow. These include: 1. shifting care from hospitals to the community, 2. from analogue to digital, 3. and sickness to prevention. In the short-term, a range of action is being taken by the NHS 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. There is also a focus on 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. We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.