Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0681, written 10 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 | 10 Dec 2024 |
|---|---|
| Reference | 2024-0681 |
| Deceased | Karen Dack |
| Coroner | Dianne Hocking |
| Coroner area | Leicester City and South Leicestershire |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Department of Health & Social Care 39 Victoria Street London SW1H 0EU By Email only to :- 1 CORONER I am Mrs D HOCKING, His Majesty's Assistant Coroner for the coroner area of Leicester City and South Leicestershire. 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 29 May 2024 I commenced an investigation into the death of Karen Pamela DACK aged 43. The investigation concluded at the end of the inquest on . The conclusion of the inquest was that: The cause of death was established as: I a Sepsis I b Spontaneous Bowel Perforation I c Sigmoid Diverticular Stricture II 4 CIRCUMSTANCES OF THE DEATH Ms Dack had worsening symptoms of stricture and obstruction of the bowel. She had a colonoscopy on the 21 December 2023 which showed a stricture of the bowel. In April 2024, following admission via the emergency department, planned urgent surgery did not happen because there were no intensive care beds and her condition had appeared to have resolved. She was fast tracked to have an elective bowel resection on the 17 May 2024. On the 02 May 2024, following another emergency Regulation 28 – After Inquest Document Template Updated 16/05/2023 admission she again had urgent surgery planned but it did not go ahead due to her surgery being superseded by other more urgent cases. Her treating consultant told this inquest that it was his plan to take Karen back to theatre the next day but this was not clearly communicated and Karen was discharged with the elective surgery still to take place as previously planned on the 17 May 2024, which was the plan written in the electronic records. There was no assessment by any senior surgeon as to Karen’s fitness to be discharged and there was confusion about the management plan by the nurses on the ward. Karen re-presented to the emergency department four days later with worsening abdominal pain, vomiting and diarrhoea. She had not suffered a perforated bowel at the time of admission, but the plan was that she should be taken to theatre for a laparoscopic bowel resection the following day. Due to the volume of operations at this time this did not take place on the 07 May and was planned for the next day. It is clear from the evidence that Karen’s condition deteriorated suddenly on the morning of the 08 May 2024, most likely due to perforation of her bowel. Once this was recognised surgery was completed urgently but Karen did not recover and became septic and sadly died despite the surgeons attempts to save her with several further operations. The evidence heard is that had Karen had any of the planned operations before her bowel perforated on the 08 May she would have survived. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my In the circumstances it opinion there is a risk that future deaths could occur unless action is taken. is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) That this lady’s surgery was cancelled at the last minute on three separate occasions due to lack of theatre availability. I heard from the Deputy Clinical Director at Leicester Royal Infirmary that there has been a review of how patients are prioritised and whether they are effectively using their emergency theatre capacity. He said that ‘the obvious problem with emergencies is they are unpredictable, there are times when the emergency list only requires one theatre and there are times when there are so many cases on the emergency list that we need to cancel elective cases in order to accommodate them and SOPs are in place around this.’ He went on to say that there were no imminent plans for theatre expansion at the University Hospitals of Leicester (UHL) and that the categorisation and access to emergency theatres are probably as good as they can get with the currently available resources. I am concerned that whilst UHL is doing its utmost to deal with this problem the fact is that regardless of how patients are categorised there are still the same number of theatres available and that this issue will happen again, and further deaths may occur. 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 January 31, 2025. I, the coroner, may extend the period. Regulation 28 – After Inquest Document Template Updated 16/05/2023 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 Chief Coroner and to the following Interested Persons: The deceased’s family 1) 2) University Hospitals of Leicester 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. 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 Dated: 10/12/2024 Mrs D HOCKING His Majesty's Assistant Coroner for Leicester City and South Leicestershire Regulation 28 – After Inquest Document Template Updated 16/05/2023
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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 20 February 2025 Our ref: HM Coroner Dianne Hocking The Coroner’s Court Town Hall Town Hall Square Leicester LE1 9BG By email: Dear Mrs Hocking, Thank you for the Regulation 28 report of 10 December 2024 sent to the Department of Health and Social Care about the death of Karen Dack. I am replying as the Minister with responsibility for Health (Secondary Care). Firstly, I would like to say how saddened I was to read of the circumstances of Karen Dack’s death, and I offer my sincere condolences to Karen’s family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over Karen Dack’s last minute surgery cancellations. This happened on three separate occasions following emergency admission due to lack of theatre availability. See ‘matters of concerns’ outlined in the PFD report. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. NHS England has raised your concerns directly with the Integrated Care Board (ICB) relevant to this case (NHS Leicester, Leicestershire and Rutland ICB). Prior to the issuing of the Regulation 28, the Trust had completed a mortality review and identified some immediate actions that were instigated to reduce future risk. These included a change to the process for emergency theatre booking and improvements in tallying documentation across different systems. University Hospital of Leicester NHS Trust’s (UHL) clinical teams are fully focused on ensuring that the acute deterioration of patients is acted on promptly and their senior clinical decision makers act in a manner to ensure appropriate clinical risk is balanced with operational pressures. The case also met the national criteria for a Patient Safety Incident Investigation (PSII), and this is being undertaken in the Trust. NHS Leicester, Leicestershire and Rutland ICB is engaging with the Trust and awaits the outcome of the PSII. Regarding your concern over theatre capacity, the Trust are focussing on fully utilising all elective theatre capacity, to free up theatre capacity for urgent care; notably at Loughborough, Melton and the new East Midlands Planned Care Centre at the Leicester General Hospital site. Additionally, a new day-case theatre is replacing an old dormant facility at Hinckley, with the build due in 2026. All of this should allow activity to be undertaken more efficiently within the capacity available and free up time for the larger or more urgent cases in the most appropriate acute setting. The Trust is exploring expansion of theatre capacity through the ‘surgical hub’ programme. Dedicated and protected surgical hubs transform the way the NHS provides elective care by focusing on providing high volume low complexity surgery, as recommended by the Royal College of Surgeons of England. NHS England are also undertaking a thorough investigation of this case under the Patient Safety Incident Response Framework (PSIRF) process to ensure learning is taken from this case going forward. NHS England will also be flagging this Regulation 28 through to their Quality Committee this month. This case will also be taken to the Leicester, Leicestershire and Rutland (LLR) system-wide Learning from Deaths forum, chaired by the ICB Deputy Medical Director to ensure learning is shared across the system. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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