Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0566, written 22 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 | 22 Oct 2024 |
|---|---|
| Reference | 2024-0566 |
| Deceased | Joan Knight |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham 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.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: University Hospitals Birmingham NHS Foundation Trust CORONER I am Louise Hunt, Senior Coroner for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 11 June 2024 I commenced an investigation into the death of Joan Margaret KNIGHT. The investigation concluded at the end of the Inquest . The conclusion of the inquest was; Died from the consequences of a recognised complication following treatment for severe coronary artery stenosis CIRCUMSTANCES OF THE DEATH Mrs Knight suffered an acute inferior wall myocardial infarction on 16/05/24 and had treatment by way of angioplasty to her right coronary artery with a stent being fitted. The procedure was complicated as she was found to have significant calcium build up in the coronary artery. It was also noted that the left anterior descending artery had severe narrowing. Initially after the procedure she was pain free; however she began to experience further chest pain on 18/05/24 which was treated with medication. The chest pain recurred on 20/05/24 and a further procedure to insert a stent into the left anterior descending artery was undertaken on 21/05/24. During the procedure access was difficult and significant calcification was noted. During ballooning the coronary artery ruptured and was successfully treated with a stent. Whilst initially stable after the procedure her condition deteriorated, and she presented with an unrecordable blood pressure. A bedside echocardiogram confirmed a collection of blood around the heart and an emergency pericardial aspiration was undertaken and she was taken back to the cardiac catheter lab where a covered stent was fitted to try to treat the bleeding at the site of the previous perforation. The bleeding was difficult to control and arrangements were made to transfer her to the Queen Elizabeth Hospital where a CT scan confirmed bleeding in the abdomen. She was taken to theatre where no site for bleeding was found in the abdomen; however a small perforation in the right ventricle was identified and repaired which was likely caused when the emergency aspiration procedure was undertaken. Sadly, she developed multi organ failure in the post operative period and passed away on 25/05/24. Based on information from the Deceased’s treating clinicians, the medical cause of death was determined to be: 1a Multiple organ failure 1b intrabdominal bleeding from chest compressions and ventricular bleeding secondary to emergency pericardial aspiration (operated) 1c cardiac tamponade 1d treatment for severe stenosis of the left anterior descending coronary artery leading to perforation and bleeding II Myocardial infarction (treated) 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. The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mrs Knight. I have also sent it to the Medical Examiner, ICS, NHS England, CQC. 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. 22 October 2024 Signature: Louise Hunt Senior Coroner for Birmingham and Solihull 5 6 7 8 9
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.
Executive Office of the Chair & Chief Executive
Chair
Chief Executive
Executive Office
:
:
:
11th December 2024
Mrs Louise Hunt
HM Senior Coroner for Birmingham and Solihull
By way of email only:
Dear Mrs Hunt
Inquest touching the death of Mrs Joan Knight
Response to Regulation 28 Report to prevent future deaths
I am writing in response to the Regulation 28 notice issued following the conclusion of the
inquest on 21 October 2024, into the death of Mrs Joan Knight at Queen Elizabeth Hospital
Birmingham (part of University Hospital Birmingham NHS Foundation Trust). I extend my
sincere apologies to Mrs Knight’s family.
I note your narrative conclusion was that Mrs Knight died from the consequences of a
recognised complication following treatment for severe coronary artery stenosis.
I further note your concern regarding the risk of future deaths, which has been addressed
below. The focus of the actions has been at the Queen Elizabeth Hospital Birmingham
(QEHB) but the learning identified in this response has been shared with each of the
responsible Hospital Medical Directors and Directors of Nursing covering QEHB, Birmingham
Heartlands Hospital and Good Hope Hospital respectively for implementation.
We have carefully considered the concerns raised within your report to prevent future deaths,
relating to the conduct and recording of mortality reviews.
Concern:
The mortality review that was undertaken in this case was completed incorrectly and
contained contradictory terms about whether the death was avoidable. This raises a
concern that mortality reviews are not being concluded correctly and that there could
be inadequate learning from cases raising a risk of future deaths.
As part of our disclosure to you for the inquest we provided a copy of the mortality review
completed by the speciality responsible for Mrs Knight at their M&M meeting.
Following review and discussion with the speciality we have learnt that they are one of only
two specialties still using legacy IT software (Dendrite) for capturing mortality reviews. The
software allowed the input of multiple methodology coding scores for recording; Quality of
Care, Preventability and Categorisation/Nature of Death, which could potentially appear
contradictory.
We have taken the following immediate steps to rectify this concern and reduce the likelihood
of reoccurrence:
1. We have requested that the speciality use the three methodology coding scores
recommended by the Learning from Deaths Team in line with the rest of the Trust and
we have disabled the use of all other methodology coding fields on the software.
2. We have identified the specialities within the Trust who are currently using the
Dendrite software for capturing mortality review. (Cardiology plus one other speciality,
both on the Birmingham Heartlands Hospital site)
3. A new Mortality & Morbidity recording platform has been developed and is to be piloted
prioritising the two identified specialities using the Dendrite software.
In addition, the following planned steps are due to be completed within the next 12 months:
1. A New Mortality & Morbidity recording platform is to be rolled out across the remainder
of the Trust once piloted.
2. Updated Mortality & Morbidity standards are to be published and readily available on
the Trust intranet.
3. The introduction of a Trust Mortality Committee, commencing in December 2024.
I would like to assure you that the concerns raised within the Regulation 28 Report have been
taken extremely seriously, which I hope is demonstrated in the steps we have taken in
reviewing and strengthening our systems, processes and training provision to our teams.
Yours sincerely
Chief Executive
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