Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0527, written 4 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 | 4 Oct 2024 |
|---|---|
| Reference | 2024-0527 |
| Deceased | Marina Young |
| Coroner | James Adeley |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Lancashire Teaching Hospitals 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO
Lancashire Teaching Hospitals NHS Trust
, Director of Nursing at
1
CORONER
I am Dr James Adeley, HM Senior Coroner for the coroner area of Lancashire and
Blackburn with Darwen
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 March 2023 I commenced an investigation into the death of Marina Sharon Young
aged 46 the investigation concluded at the end of the inquest on Friday, 27 September
2024, the conclusion of the inquest was Marina Sharon Young died on 22 June 2022
after a 39 hour wait for a hospital bed in Royal Preston Hospital's Accident &
Emergency Department. Her death, due to asthma, was preventable and was
caused by neglect characterised both by a gross failure to provide appropriate
assessment and medical care and an inadequate escalation of her management
to specialist physicians or ITU.
The cause of death was 1a Aspiration b asthma.
4
CIRCUMSTANCES OF THE DEATH
Marina was born with spina bifida and as a result had decreased sensation from the waist
down and reduced motor power in her legs which resulted in the use of an adapted car.
Had undergone a bladder transplant as a child and, due to a lack of sensation, needed to
self-catheterise every 3-4 hours with a disposable catheter. However, when Marina was
unwell, she required assistance with catheterisation, and she was unable to complete the
task by herself. Marina also wore incontinence pads.
On the morning of 20 June 2024 Marina's chest infection precipitated an asthma attack.
Marina was admitted to Royal Preston Hospital Accident & Emergency Department (A &
E) where she was initially appropriately assessed and treated by the A & E doctor. At this
time, the hospital was full and during the remainder of Marina's 39 hour stay A & E had a
'bed block' preventing transfer of patients out of A & E was in place and would have been
known to senior nursing staff. Such holding of patients in A & E was described around this
time as "continuous". Marina, according to the British Thoracic Society predictive peak
flow rates was throughout her stay in A & E in the "life-threatening" asthma category.
Marina's asthma attack had an 80% chance of survival but, due to the acute medical
team's substantial failures of medical management, inadequate treatment, insufficient
direction of the nursing staff for observations and a lack of referral to either respiratory or
ITU specialist teams, Marina died at approximately 10 AM on 22 June 2024. During this
time Marina's nursing needs were neither assessed nor met, despite it being known to the
senior nursing staff that Marina, having complex nursing needs due to her spina bifida,
would be spending an extended period of time in the A & E. During Marina's 39 hour stay
in A & E none of the six nurses involved with Marina undertook a nursing assessment of
her toileting needs and failed to offer a catheter, assist with catheterisation or change the
incontinence pad. The nursing staff made no assessment of Marina's sensory deficits due
to spina bifida and relied upon patient reports for pressure area care in an overweight and
incontinent patient, who remained sat in a chair due to her breathing difficulties for almost
all of the 39 hours. A falls risk assessment was completed, albeit with substantial errors.
When Marina died, she was still wearing the shoes that she was wearing when she arrived
in the Department 39 hours earlier and which she could not remove without assistance.
It was accepted that A & E is geared up for short-term stays dealing with acutely ill
patients. Any patients remaining in A & E beyond the expected period are being nursed
in an area that is not designed for their needs, without the benefit of specialist nursing
staff and the risks they are exposed to are consequently increased.
Despite the Matron for A & E being on the Trust's level 3 STEIS investigation, not a single
concern regarding the nursing care provided was identified.
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:
1. When hospital management are aware that, due to hospital capacity issues or
other reasons, patients will be spending more than the usual expected time in A
& E, A & E managers should be alerted of this perspective status as soon as
possible.
2. Any patient remaining in A & E beyond the usual expected time should have an
assessment of their care needs.
3. Care needs of patients held in A & E, particularly those with complex care
needs, should be identified and managed.
4. Asthma is a common condition. However, A & E lacked nurses with any
knowledge of when basic assessment such as peak flow should be taken and
no request for assistance from a specialist ward was made.
5. Although the nursing staff made attempts to engage the acute medical team, no
attempt was made to escalate problems identified by the treating nurses to
senior nursing staff
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday, 29 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 and how such action has been audited to ensure any changes are
effective. 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, the family I have also sent it to Care Quality Commission 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
[DATE]
[SIGNED BY CORONER]
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.
Tel: Email: Ref: Chief Medical Officer Royal Preston Hospital Sharoe Green Lane Fulwood PRESTON PR2 9HT 29 November 2024 Dear Dr Adeley, RE: Inquest Marina Young. Regulation 28 Report Further to your email communication of 4th October 2024 and the associated Regulation 28 report please find attached action plan formulated in response which addresses each of the concerns that you raised. We will be pleased to share further updates as the actions are progressed if this would assist you further. Can I offer my apologies that you had cause to issue the Regulation 28 report. I hope that our response assures you of our commitment to learn both from Ms Young’s death, and from the subsequent inquest. Following the inquest, Mr John Howles (Associate Director of Patient Experience and Engagement) met with Ms Young’s sister Michelle to offer further apologies and to listen to her concerns. She has kindly offered to assist with overseeing improvements identified in the action plan for which we are grateful. We will forward the action plan to her and update her on progress in line with her wishes. Please do let me know if we can be of further assistance. Yours sincerely Chief Medical Officer– Lancashire Teaching Hospitals NHS Foundation Trust
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