Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0540, written 9 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 | 9 Oct 2024 |
|---|---|
| Reference | 2024-0540 |
| Deceased | Chamali Bibi |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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: Prevention of Future Deaths report
Chamali BIBI (died 04.03.23)
THIS REPORT IS BEING SENT TO:
1.
National Medical Director
NHS England
Wellington House
133-135 Waterloo Road
London SE1 8UG
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 7 March 2023 I commenced an investigation into the death of
Chamali Bibi, aged 39 years.
The inquest was listed for 15 August 2023, but the investigation was not
concluded until the end of the inquest on 25 September 2024.
I made a narrative determination at inquest, which I now attach.
4
CIRCUMSTANCES OF THE DEATH
Ms Bibi underwent a right periacetabular osteotomy (PAO) on 01.03.23,
during which she suffered haemorrhagic shock that led to a stroke that
evening.
1
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 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.
As you will see from the narrative determination attached, there were
several matters requiring attention at the Royal London Hospital.
However, I do not intend to make a prevention of future deaths (PFD)
report to Barts Health, because I was given undertakings in court that
these matters have already been addressed.
The issue that I bring to your attention is this. At inquest, I heard
evidence that PAOs should only be conducted by surgeons expert in this
procedure. I heard that only those undertaking this procedure frequently,
with mentor feedback on the surgery taking into account the post
operative imaging, can gain the necessary experience to become expert.
However, the majority of the surgeons on the specialist register are the
only practitioners within their trust performing the surgery and the
majority undertake fewer than ten per annum each. Further, the register
is voluntary. Outliers do not appear to have been flagged.
It is not clear to me whether all trusts recognise that the PAO is a different
procedure, rather than simply being a different technique.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 2 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.
8
COPIES and PUBLICATION
2
I have sent a copy of my report to the following.
•
•
• HHJ Alexia Durran, the Chief Coroner of England & Wales
, Chief Medical Officer for England
, husband of Chamali Bibi
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. She may send a copy of this report to any person who
she 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.
9
DATE SIGNED BY SENIOR CORONER
09.10.24 ME Hassell
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.
Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
National Director of Patient Safety
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
25 November 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Chamali Bibi who died on
4 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9
October 2024 concerning the death of Chamali Bibi on 4 March 2023. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Chamali’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Chamali’s care have
been listened to and reflected upon.
Your Report raises the concern that periacetabular osteotomy (PAO) procedures may
not be being carried out by suitably experienced practitioners and that Trusts may not
recognise it as being a specialist procedure, as opposed to a surgical technique. My
response to the Coroner has been informed by specialist orthopaedic clinical opinion.
The Coroner is correct in their assertion that PAOs are a specialist procedure which
should be undertaken only by clinicians with the requisite training and experience,
who perform the procedure regularly. Clinicians should keep a record of their
procedures and their outcomes, and it should form part of their annual appraisal and
reaccreditation processes. Surgeons who have not undertaken the required training
and fellowships should not perform PAO procedures. It is NHS England’s opinion that
Orthopaedic Surgeons will already be aware that a PAO is a specialist procedure, and
that Trusts should therefore be aware of this too.
It is not appropriate for NHS England to provide further comment on the concerns
raised in your Report, based on the information provided. I understand from your
Report that you are satisfied that Barts Health NHS Trust have addressed several
matters which you felt required further attention, and undertakings were given to you
in court in this respect. Your Report has also been sent to my regional colleagues in
London as part of our internal Regulation 28 assurance processes. It is not therefore
appropriate for NHS England to provide further comment on these specific concerns.
NHS England are not the responsible organisation for the relevant clinical and
professional standards and guidance raised in this matter. The Coroner may wish to
refer to the Royal College of Surgeons (RCS) of England or the British Orthopaedic
Association (BOA) if they feel they require further information.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Chamali are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Director of Patient Safety
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