Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0669, written 4 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2024 |
|---|---|
| Reference | 2024-0669 |
| Deceased | Patricia Curtis |
| Coroner | Elizabeth Gray |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Papworth Hospital NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS England 2 Secretary of State for Health 1 CORONER I am Elizabeth GRAY, Area Coroner for the coroner area of Cambridgeshire and Peterborough 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 21 April 2021 I commenced an investigation into the death of Patricia CURTIS aged 80. The investigation concluded at the end of the inquest on 21 November 2024. The conclusion of the inquest was that: Patricia Curtis died as a result of a known, but extremely rare complication of necessary post operative treatment 4 CIRCUMSTANCES OF THE DEATH Mrs Curtis underwent mitral valve repair, tricuspid valve repair, coronary artery by pass grafting x 3 and atrial appendage exclusion on 17 March 2021 at Royal Papworth Hospital. Her post operative recovery was lengthy and she was repatriated to Bedford Hospital on 1 April 2021. On 2 April 2023 following arrival at Bedford Hospital Mrs Curtis deteriorated rapidly in the early hours of the morning. Post mortem examination determined that her cause of death was a haemothorax which on the balance of probability had started to develop gradually following a removal of her chest drain at Royal Papworth Hospital before transfer to Bedford Hospital. Clinical signs of the haemothorax were first identifiable at 1am on 2 April 2021 when Mrs Curtis' medical assessment detected decreased air entry on her left side following prior examination results which showed equal air entry. Haemothorax did not form part of the differential diagnosis for Mrs Curtis at 1am on 2 April 2021 and she continued to be treated for her presenting complaints of fast atrial fibrillation, low blood pressure and severe heart failure and possible myocardial ischaemia due to low blood pressure. A chest X-ray was not considered to be necessary as Mrs Curtis was not presenting with a primary lung cause and her respiratory system did not seem particularly affected at that time. It is not possible to say whether a chest X-ray would have identified a haemothorax. It was recognised by the treating clinicians that Mrs Curtis was very unwell and it was determined that Mrs Curtis would be unlikely to survive Intensive Care Unit care. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Regulation 28 – After Inquest Document Template Updated 30/07/2021 Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to potential delay in providing life saving care and treatment. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 January 2025. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Patricia Curtis Bedford Hospital Royal Papworth Hospital who may find it useful or of interest. 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 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 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 Dated: 04/12/2024 Elizabeth GRAY Area Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
From Minister of State for Care 39 Victoria Street London SW1H 0EU 28 January 2025 Our ref: HM Coroner Elizabeth Gray Cambridgeshire and Peterborough Coroner’s Office Lawrence Court, Princes Street, Huntingdon PE29 3PA By email: Dear Ms Gray, Thank you for the Regulation 28 report of 4 December 2024 sent to the Secretary of State / the Department of Health and Social Care about the death of Patricia Curtis. I am replying as the Minister with responsibility for hospital discharge. First, I would like to say how saddened I was to read of the circumstances of Patricia Curtis’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the lack of uniformity of discharge notes across hospital trusts and the consequential risk that when patients are transferred to another clinical setting, clinicians could be missing the essential patient information they need to provide timely care and treatment. As the Minister responsible for hospital discharge, I recognise the importance of ensuring people are discharged from hospital and transferred to another clinical setting in a safe way. Doing so will help to ensure that people are able to receive the life-saving investigations and treatment they need without delay. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Individual trusts are responsible for their own discharge policies. I am therefore grateful to NHS England for advising that, since the report, they have engaged with Royal Papworth Hospital NHS Foundation Trust. I welcome the steps taken by the trust’s Discharge Planning Group around involvement of next of kin in patient transfers. I look forward to engaging with NHS England to understand how this develops. While individual trusts are responsible for their own discharge policies, national statutory hospital discharge guidance has been published (last updated January 2024) which details the national discharge requirements for all NHS Trusts, commissioning bodies, local authorities, and relevant sectors, such as care providers. The guidance sets out how local areas should plan and implement hospital discharge services in order to support safe and timely discharge for all individuals, including the sharing of accurate timely information across organisational boundaries. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Ms Elizabeth Gray
HM Area Coroner
Cambridgeshire & Peterborough Coroner’s Service
Lawrence Court
Princes Street
Huntingdon
PE29 3PA
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
22 January 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Patricia Curtis who died on
2 April 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4
December 2024 concerning the death of Patricia Curtis on 2 April 2021. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Patricia’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Patricia’s care have
been listened to and reflected upon.
Your Report raises the concern that hospital discharge notes are not uniform across
hospital Trusts. This carries the risk of essential patient information not being available
to treating clinicians when a patient is received into a new clinical setting, leading to a
potential delay in providing life-saving care and treatment.
Individual Trusts are responsible for their own discharge policies. However, the
Hospital Discharge Service guidance and operating model, published by the
Department of Health and Social Care (DHSC) in August 2020 and last updated in
January 2024, details the national discharge requirements for all NHS Trusts,
community interest companies, private care providers of acute care, community beds
and community health services and social care staff in England. The guidance, which
is based on successful discharge to assess principles, aims to ensure that all
individuals are discharged from hospital in a safe, appropriate and timely way.
A set of role-based hospital discharge actions cards are also available, which
summarise the responsibilities for key roles and staff members within the hospital
discharge process.
NHS England has engaged with the Royal Papworth Hospital NHS Foundation Trust
regarding your Report. We note that, in response to your concerns, their Discharge
Planning Group have taken steps to improve their processes for ensuring that next of
kin are updated on patient transfers. They advise that there were no concerns
regarding the quality or format of their discharge summaries.
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
Patricia, 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 Medical Director
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