Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0536, written 8 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 | 8 Oct 2024 |
|---|---|
| Reference | 2024-0536 |
| Deceased | David Martin |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| 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.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Medical Director, Royal Cornwall Hospital 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 8/10/24, I concluded the inquest into the death of David Charles Martin who died in RCHT on 17/9/22. I recorded the cause of death as: 1a) Left ventricular cardiac failure (post-stenting) 1b) Coronary artery thrombosis 1c) Coronary artery disease II) Atrial fibrillation; Chronic kidney disease I recorded a conclusion of Natural Causes. 4 CIRCUMSTANCES OF THE DEATH Mr Martin was an 83-year-old man with a history of progressive heart failure. He was admitted into Royal Cornwall Hospital on 30/8/22 with deteriorating symptoms. He had a diagnostic angiogram on 5/9/22 before a decision was made at a cardiology MDT on 12/9/22 that he was not for surgical intervention and was offered stenting (PCI) instead. The procedure took place on 16/9/22. It was Trust policy that patients undergoing PCI should have dual anti-platelet therapy (DAPT.) In error, Mr Martin was prescribed Aspirin only and the oversight was only identified post-operatively when Mr Martin was immediately given a loading dose of a second anti-platelet therapy. Mr Martin collapsed later that afternoon. He was resuscitated but then deteriorated and died in the hospital on 17/9/22. It is unlikely the cause of Mr Martin's collapse was a clot in an inserted stent and thus the oversight in the provision of a second anti-platelet therapy was not causative of Mr Martin's demise. 1 Information Classification: CONTROLLED 5 CORONER’S CONCERNS During the course of these inquests, the evidence has 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. 1) The inquest heard evidence that the locum SHO involved in the care of Mr Martin was 9 days into a 3-4 month period of cover. She had not received any cardiology induction and was unaware of the Trust DAPT policy regarding PCI patients. It was accepted that while it was a challenge to ensure locums who covered 1-2 shifts had a thorough induction, where one was being asked to work in the service for an extended period of time, it was necessary that there was a proper induction process. The inquest heard changes have already been made in this regard. 2) There were multiple opportunities where the fact Mr Martin was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues. 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. The inquest heard from Matron as well as Drs and . All felt changes could be made to the cardiac cath lab pack and the WHO checklist that would make the process more robust and prevent similar instances in the future. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 December 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. 2 Information Classification: CONTROLLED 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - The family of Mr Martin 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] 8/10/24 3
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.
Chief Medical Officer’s Office Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 01872 250000 6 December 2024 Andrew Cox Senior Coroner for Cornwall and the Isles of Scilly H.M Coroner’s Office Pydar House, Pydar Street Truro, Cornwall TR1 1XU Dear Mr Cox Re: Death of David Charles Martin - R28 PFD Report & letter I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the 10th of October 2024, issued as a result of the inquest into the death of Mr Martin which took place on 8th October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Martin for their loss. During the course of the inquest, the evidence revealed matters giving rise to concern. These are as follows: • Could changes be made to the cardiac catheter lab pack and the WHO checklist that would make the process more robust and prevent similar incidents in the future. • Could changes be made to the induction programme for locum doctors. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern. Can changes be made to the cardiac catheter lab pack and WHO checklist: The wording in the PCI pack has been reviewed in order to make the provision of Dual Anti- Platelet Therapy clearer to both the medical and nursing team. The proposed revised wording was first agreed by the Cardiology team and was then sent to the Safer Surgery Group (SSG) for ratification and approval. SSG approved the changes at a meeting on 15 November 2024. The revised wording was also submitted to the Forms Review Group on 13 November 2024 and they were ratified and agreed by this group on 18 November 2024. The updated forms have been sent to the publishers and are currently awaiting return. The Local Safety Standards for Invasive Procedure (LocSSiP) will be updated and will be available on the intranet for staff. A copy of the updated paperwork can be provided if required upon return from the publishers. Can changes be made to the Induction Programme for locums: The Trust is developing a training package for our Roskear Nursing Team and we are in the process of amending our nursing, junior doctors and locum induction programmes to include catheter lab pack and preparation. This is underway and is expected to be completed by 31 December 2024. To summarise the above, the Trust have taken the following actions 1. Reviewed and amended the wording in the PCI pack regarding provision of Dual Anti- Platelet Therapy. 2. Sent the revised wording to Forms Review Group and Safer Surgery Group for ratification and approval. 3. Sent updated forms to the publishers. 4. Update the Local Safety Standards for Invasive Procedures (LocSSip). 5. Develop a training package for Roskear Nursing teams – due for completion by 31 December 2024. 6. Add catheter lab packs and preparation to Nursing induction – due for completion by 31 December 2024. 7. Add catheter lab packs and preparation to Junior Doctor and Locum Induction – due for completion by 31 December 2024. I hope that this letter provides both you and Mr Martin’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths. Yours Sincerely Chief Medical Officer
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