Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0687, written 13 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 | 13 Dec 2024 |
|---|---|
| Reference | 2024-0687 |
| Deceased | Susan Evans |
| Coroner | Sally Olsen |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Portsmouth Hospitals University NHS 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.
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 Portsmouth Hospital NHS Trust 1 CORONER I am Sally OLSEN, Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 15 August 2023 I commenced an investigation into the death of Susan EVANS aged 55. The investigation concluded at the end of the inquest on 22 November 2024. The conclusion of the inquest was that: “On 11 July 2023, Susan Evans underwent elective Roux-en-Y gastric bypass surgery. The surgery went to plan and appropriate measures were taken to avoid the possibility of an anastomotic leak, a rare but recognised complication of gastric bypass surgery. Initially, Ms Evans recovered well, but she experienced abdominal pain in the early hours of 13 July 2023. It is likely that this was due to an anastomotic leak. 13 July 2023 was the first day of a junior doctors’ strike. Unrelated to this, the hospital only had the equivalent of one full time specialist bariatric nurse, who was not on duty. Contrary to Queen Alexandra hospital's written policy for gastric bypass patients, Ms Evans was not seen by a member of the specialist bariatric team on 13 July 2023 and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak. The hospital at night nursing team, who administered pain relief, were unaware of the latter requirement. In addition, Ms Evans not seen by a member of the bariatric team or any doctor prior to her discharge from hospital on the morning of 13 July 2023. Ms Evans was still in a degree of pain when she left hospital. She was re-admitted to hospital on 15 July 2023. By this point she was extremely unwell with abdominal sepsis from an anastomotic leak. She underwent remedial surgery on 15 July 2023 and a further operation was required on 25 July 2023. Despite appropriate medical care following her re-admission, her condition deteriorated, and she died at Queen Alexandra Hospital on 12 August 2023. It is likely that, if she had been seen by a member of the bariatric team on 13 July 2023, she would have been kept in hospital and would have been operated upon sooner. The failures identified contributed more than minimally to her death.” 4 CIRCUMSTANCES OF THE DEATH See Narrative Conclusion above Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: (brief summary of matters of concern) Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that: - - order to rule out anastomotic leak or bleed. There is to be a daily review by a bariatric specialist nurse, consultant or registrar. A senior doctor is to review within 2 hours if there is increased abdominal pain in In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy. Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all. The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain. The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern. 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 February 07, 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 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 13/12/2024 Sally OLSEN Assistant Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Headquarters F Level, Queen Alexandra Hospital Southwick Hill Road Cosham PORTSMOUTH, PO6 3LY Tel: 023 9228 6770 6 February 2025 Dear Ms Olsen Prevention of Future Deaths Report issued following the inquest into the death of Susan Evans held at the Portsmouth Coroner’s Court on 22nd November 2024 I write in response to the Prevention of Future Deaths (PFD) Report issued by HM Coroner following the conclusion of the inquest into the death of Susan Evans. In summary the coroner’s concerns, as expressed in the prevention of future deaths report are that, in contravention of the Trust’s post operative policy for patients who have undergone gastric bypass surgery, Susan Evans: 1. Was not seen by a bariatric specialist nurse, consultant or registrar on her final morning as an inpatient the morning she was discharged. 2. Was not reviewed by a senior doctor within 2 hours of increased abdominal pain in order to rule out anastomotic leak or bleed. And, in contravention of expected practice she: 3. Was not seen by a member of the specialist bariatric team prior to discharge. In response to the concerns set out above, there is already a policy in place which covers points 1 and 2. Unfortunately, on this occasion, it was sadly not followed. At least in part, because it was not clearly visible in the patient’s ward notes to act as a prompt. To counter this, the Bariatric lead surgeon has written a Bariatric Discharge Protocol (the new protocol) which has been incorporated into the bariatric pathway booklet which is completed for each patient undergoing bariatric surgery and kept in their medical notes for use by treating clinicians (doctors and nurses). This protocol requires a member of the bariatric team or suitable clinician to review the patient prior to discharge and ensure the patient’s pain is settling and controlled with suitable analgesia prior to discharge. Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 This new protocol will also address point 3. The protocol sets out a list of 8 criteria which must be fulfilled before a post bariatric surgery patient is able to be discharged. This includes a daily review by a member of the bariatric team or senior member of the Upper GI surgical team. If their clinical condition does not fit with all listed criteria, they must not be discharged without direct discussion with a bariatric consultant surgeon. The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025. Additionally, the protocol has been emailed to all surgical staff working within general surgery who will have out of hours and emergency responsibility for bariatric patients. The new protocol will also be added to the nursing surgical study day and will be raised as part of the ward level safety huddles within surgery. I hope that the contents of this letter provide appropriate assurance that the concerns raised have been addressed. Yours sincerely Chief Executive Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986
See every Prevention of Future Deaths report matching Portsmouth Hospitals University NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.