Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0563, written 16 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 | 16 Oct 2024 |
|---|---|
| Reference | 2024-0563 |
| Deceased | Phyllis Hart |
| Coroner | Emma Serrano |
| Coroner area | Staffordshire |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. County Hospital Stafford; 2. Chief Coroner; and 3. Family of the deceased. 1 CORONER I am Emma Serrano, Acting Senior Coroner of Staffordshire. 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 the 17th April 2023 2023, I commenced an investigation into the death of Mrs Hart. The investigation concluded at the end of the inquest on 16 October 2024. The conclusion of the inquest was a conclusion of natural causes. The cause of death was: 1a) Sepsis, 1b) Acute Limb Ischaemia 1c) Peripheral vascular disease II) Diabetes mellitus 4 CIRCUMSTANCES OF THE DEATH i) Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023. On the 21 Marc 2023 she started to show signs of having a ischaemic leg. On the 27th march vascular specialist review was requested. There is no vascular team located on the County Hospital, so the review was delayed for 4 days untill the Vascular Consultant was next at the County Hospital. ii) At the review, the decision was made that Mrs Hart was for palliative care only. She passed away on the 8 April 2023 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. – 1. There is no vascular team in hand at the County Hospital in Stafford, were urgent Vascular opinion required. 1 [IL1: PROTECT] 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 5 December 2024. 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 I have sent a copy of my report to the County Hospital in Staffordshire and the family of Phyllis Christina Hart. 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 16 February 2024 Miss Emma Serrano Acting Senior Coroner Staffordshire sss sss 2 [IL1: PROTECT]
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.
Trust Ref: 4 December 2024 STRICTLY PRIVATE & CONFIDENTIAL Ms Emma Serrano Acting Senior Coroner Stoke on Trent and North Staffordshire Sent via email: Email: Executive Suite Trust Headquarters Springfield City General Site Newcastle Road Stoke on Trent ST4 6QG Tel: Dear Ms Serrano Phyllis HART Further to your letter 16 February 2024 (received 18 October 2024), I am pleased to provide a response under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (Investigations) Regulations 2013, addressing your concerns surrounding the death of Phyllis Hart. Recorded Circumstances of the Death Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023. On the 21 March 2023, she started to show signs of having a ischaemic leg. On the 27 March 2023, vascular specialist review was requested. You heard evidence that there is no vascular team located on the County Hospital, so the review was delayed for 4 days until the Vascular Consultant was next at the County Hospital. At the review, the decision was made that Mrs Hart was for palliative care only. She passed away on the 8 April 2023 Concerns During the course of the inquest, you felt that evidence revealed matters giving rise for concern. In your opinion, matters for concern are as follows: 1. There is no vascular team in hand at the County Hospital in Stafford, were urgent Vascular opinion required. You reported this matter under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. In your opinion, action should be taken to prevent future deaths. Action Taken The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest seriously and indeed, I am grateful that you have raised your concerns. 1. Our vascular lead has reviewed the concern that you have raised, and we are able to confirm that UHNM provides a 24/7 vascular on-call service which is based at the Royal Stoke Hospital site. There are also vascular surgeons present at County Hospital every week day (excluding the weekend). Normally, review of the in-patients is led by , Consultant Vascular Surgeon and , Consultant Vascular Surgeon. In addition to this, and (both Consultant Vascular Surgeons) also visit County Hospital on a regular basis. This lady was referred to the service via the ‘careflow’ system which is usually a slower pathway of referral (ie rather than someone calling the Consultant on-call / on site). Requests via ‘careflow’ emerge on a list on iportal called “vascular inpatient specialty referrals”. The on-call surgeon based at Stoke will then triage these referrals and try to ensure expeditious review at County by a colleague, or instead, arrange to transfer the patient to Stoke. Whilst the team endeavor to provide prompt reviews for patients in County Hospital, we also rely on accurate information from referrers and prefer, in emergency situations, to receive direct contact rather than electronic. We will ensure that this information is further conveyed to the wards and clinicians at County Hospital so that they understand that there is always someone from the vascular team to contact, should the need arise. We do hope that the above information provides assurance that the Trust have taken the concerns raised at the inquest seriously and Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours sincerely Chief Executive
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