Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2024-0601, written 26 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Apr 2018 |
|---|---|
| Reference | 2024-0601 |
| Deceased | Yazin Elhjaje |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | Bristol NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 26th April 2018 REF: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: University Hospitals Bristol NHS Trust Trust Headquarters Marlborough Street Bristol BS1 3NG 1 CORONER lam M E Voisin Senior Coroner for Area of Avon 2 CORONER’S LEGAL POWERS | 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 18/10/2017 | commenced an investigation into the death of Yazin ELHJAJE. The investigation concluded at the end of the inquest 26th April 2018. The conclusion of the inquest was a narrative which read as follows: Yazin died from bacterial meningitis which was diagnosed on 7th October 2017. He had been unwell for about a week with a headache but since 5" October developed a fever. On 7" October at 2am he was seen at the hospital examined and discharged, he did not have a full set of observations and his discharge letter stated that meningitis had not been completely ruled out. He was discharged at 2.45 am and his condition over the day deteriorated. He was taken by ambulance to the hospital at around 5pm on 7” October 2017 but died on 8" despite the treatment provided at that time. 4 CIRCUMSTANCES OF THE DEATH Yazin Elhjaje became ill on 6th October 2017 and was taken to see his general practitioner, she was concerned about his presentation and that it could be meningitis, he was managed at home and then taken to hospital later that day with a letter from the general practitioner raising her concern. Yazin was examined and discharged with a diagnosis of sinusitis. His condition deteriorated over the next few hours and he was taken back to the hospital by ambulance, by now he was very ill, it was confirmed that he probably had meningitis, his condition deteriorated despite the treatment and he died on 8th October 2017 at Bristol Royal Hospital for Children Upper Maudlin Street Bristol The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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. — | heard during the inquest that the safety-netting advice on discharge given to Yazin’s parents was in relation to his headaches and not in relation to the differential diagnosis of meningitis. | would ask that consideration is given to the safety-netting advice provided to parents in cases where meningitis has been considered as part of the differential diagnosis as in this case. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 26" June 2018 |, 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 | have sent a copy of my report to the Chief Coroner and to the following interested persons — the family - and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. | 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. 26/04/2018 Signature ME Voisin nior Coroner Area of Avon Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
INHS University Hospitals Bristol NHS Foundation Trust Trust Headquarters Marlborough Street Bristol, BS1 3NU Tel: 0117 342 3720 Email Web-site: www.uhbristol.nhs.uk 13 June 2018 Private & Confidential Mrs M E Voisin, Senior Coroner The Coroners Court Old Weston Road Flax Bourton BS48 1UL Dear Mrs Voisin RE: Inquest 26th Aprii 2018 — Master Yazin Elnjaje — Regulation 28 Report Further to your concerns raised to University Hospitals Bristol NHS Foundation Trust in the format of a Regulation 28 Report, | am writing to confirm the Trust’s response and actions. At the inquest, | understand that you raised concerns around the safety netting advice given on discharge to Yazin’s parents, specifically in relation to the potential risk of Yazin developing a bacterial meningitis following his discharge from the emergency department. Following this incident the Emergency Department governance lead has led the development of an information leaflet to be given to families whose children present with sinusitis that includes information about rare potential complications such as meningitis. | hope that the information above has answered your concerns and reassures you that University Hospitals Bristol NHS Foundation Trust now has a safety netting process in place parents and children presenting with sinusitis. let Executive se MBay, Syess* University Hospitals Bristol NHS Foundation Trust “Y cy 0117 923 0000 Minicom 0117 934 9869 www.uhbristol.nhs.uk Our hospitals. 75a
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