Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0712, written 30 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 | 30 Dec 2024 |
|---|---|
| Reference | 2024-0712 |
| Deceased | Michael Jervis |
| Coroner | Guy Davies |
| Coroner area | Cornwall and Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Cornwall Hospitals 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.
Information Classification: PUBLIC REGULATION 28: REPORT TO PREVENT FUTURE DEATHS IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF MICHAEL RAMON JERVIS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: . Chief Executive, Royal Cornwall Hospital Trust 1 CORONER I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 21 July 2024 I commenced an investigation into the death of 69-year-old Michael Ramon Jervis. The investigation concluded at the end of the inquest on 24 October 2024. The medical cause of death was found to be 1a Neutropenic Sepsis 1b Chemotherapy II Germ Cell Testicular Cancer The four questions - who, when, where and how – were answered as follows … 1 Information Classification: PUBLIC Michael Ramon JERVIS died on 16 July 2023 at Royal Cornwall Hospital Truro from Neutropenic Sepsis, a recognized complication of chemotherapy treatment for Testicular Cancer. There was a 20-hour delay in the administration of antibiotics from the point at which clinical observations repeatedly indicated that antibiotics were clearly required. This delay in the administration of antibiotics more than minimally contributed to his death. The conclusion as to the death is … Michael Ramon JERVIS died from a recognized complication of necessary medical treatment contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH 1. Mike was diagnosed with testicular cancer in May 2023 at Royal Cornwall Hospital Truro (RCHT). The cancer was treatable. The treatment plan was four cycles of chemotherapy. The aim of treatment was curative. Prior to the cancer diagnosis Mike was an independent, fit, and active man. 2. Mike underwent three cycles of chemotherapy. The cancer responded well to chemotherapy with the tumour markers falling from 18,000 to 18 by 5 July 2023. 3. Mike was discharged home on 9 July 2023 with a plan to admit him for the fourth round of chemotherapy. 4. However, Mike was re-admitted on 13 July 2023 to RCHT after becoming unwell. Bloods were taken on admission which revealed neutropenia. This is a condition which involves a significant weakening of the immune system and indicated a high risk of sepsis. 5. At 1600 hours 13 July 2023, an acute oncology nurse specialist recorded on Mike’s notes that antibiotics should be administered should Mike’s temperature fall below 36 or rise above 37.5. This note is consistent with hospital policy and guidance. 6. The court found that infections and sepsis are a recognized complication of chemotherapy because the treatment leaves patients immuno- compromised. 7. The court heard that a bundle of six measures are required when clinical indicators of sepsis are present, known as the ‘Sepsis Six’ bundle. The indicators for implementation of sepsis six, particularly for those immuno-compromised, include temperature above 37.5, below 36. 8. The six measures include administering fluids and administering antibiotics. The court found that of the six measures, antibiotics is the most important and should be administered within 60 minutes. 9. The court heard that the Sepsis Six bundle has been policy since 2006 at RCHT and nursing staff and doctors are expected to be aware of and implement sepsis six when indicated. 10. The first indication that sepsis six should be implemented was at 1710 hours on 13 July 2023 when observations gave a NEWS score of 4 in 2 Information Classification: PUBLIC which low temperature (temp 35.6) and low blood pressure (78/42) should have resulted in a medical review and met the low threshold for IV antibiotics. 11. Thereafter numerous observations were taken over the following hours indicating that Mike met the low threshold for IV antibiotics. 12. In total, there was a 20-hour delay in the administration of antibiotics from 1710 hours on 13 July 2023 until 14:30 hours the following day. 13. The court found that this delay in the administration of antibiotics more than minimally contributed to his death and amounted to neglect. 5 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) Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should be triggered and that antibiotics were required but this did not happen. (2) There was an absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six. 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 26 February 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family. 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 3 Information Classification: PUBLIC 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 30 December 2024 Guy Davies 4
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.
Date: 20 February 2025
Tel: 01872 250000
Chief Medical officer’s office
Royal Cornwall Hospital
Truro
Cornwall
TR1 3LJ
Private and Confidential
Mr. Guy Davies
Assistant Coroner for Cornwall and the Isles of Scilly
Pydar House
Pydar Street
Truro
Cornwall
TR1 1XU
Dear Mr Davies,
Re: The Late Michael Ramon Jervis – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 30 December 2024
and received on the 31 December 2024. This was issued as a result of the inquest into the death of
Mr Jervis which concluded on 24 October 2024.
I would like to take this opportunity to express my sincerest condolences to the family of Mr Jervis
for their loss.
During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Repeated observations and NEWS scores were taken by numerous staff members which
indicated that sepsis six should have been triggered and that antibiotics were required, but
this did not happen,
• There was an absence of a digital alert on hospital software, which could have alerted staff
for the need to implement sepsis six.
Please find below the response from the Trust and the detail of the actions being taken in relation to
the above concern.
Repeated observations and NEWS scores were taken by numerous staff members which
indicated that sepsis six should have been triggered and that antibiotics were required but
this did not happen:
The Trust has undertaken the following action since the death of Mr Jervis; In the Acute Medical
Unit (AMU) the matron has formulated an action plan to promote learning within the ward and
wider care-group. This plan includes improving and monitoring compliance with mandatory sepsis
training.
The actions are:
a. To improve policy awareness and compliance by implementing a sepsis safety brief
which will be shared Trust wide. This will be signed off and shared by April 2025. A
copy can be provided if required.
b. The patient’s story will be shared with AMU staff (following consent), emphasising
patient impact, to enhance staff awareness and understanding. The aim is to have
this completed within the next six months and this will specifically focus upon
neutropenic sepsis, hypothermia and the sepsis six bundle.
c. An educational awayday is being arranged for AMU staff, with a focus on sepsis and
the deteriorating patient. This will be convened within the next six months.
d. To increase the compliance with sepsis training, improving to ‘amber’ (80%)
compliance within four months and reaching a target of ‘green’ (90%) compliance
within six months (excluding those on leave (i.e. maternity leave)
e. Sharing learning via Governance Leads in their areas at their local Governance
meetings.
Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now
part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have
been arranged for our doctors with regards to sepsis and this has been implemented.
Page 2 of 4
Image 2. Sepsis Screening Tool.
To continue to raise awareness and increase visibility, the Trust’s sepsis lead is applying the
sepsis screening tool to all blood pressure machines.
Sepsis awareness also forms part of the sepsis safety brief and communications have commenced
from February 2025 with a sepsis digital sidebar and screen savers on all Trust computers.
Page 3 of 4
There was an absence of a digital alert on hospital software, which could have alerted staff
for the need to implement sepsis six:
Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is
implementing a new e-Care digital electronic patient record (EPR) system and the sepsis lead nurse
will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the
‘sepsis six’ needs to be actioned.
To summarise the above, the Trust are taking the following actions
1. Sepsis safety brief shared trustwide.
2. A patient story to be shared with AMU, which will have a focus on neutropenic sepsis,
hypothermia and the sepsis bundle.
3. Sepsis training for nurses and health care assistants has become part of the mandatory and
essential training from August 2024.
4. Sepsis update training has commenced with our doctors.
5. An educational awayday to be arranged for AMU staff, with a focus on sepsis and the
deteriorating patient.
6. A training poster will be placed for reception staff in acute clinical areas (e.g. ED) to ensure
that they are aware of the need to flag patients requiring neutropenic sepsis care.
7. RCHT plans to implement a sepsis trigger within the new E-care system – scheduled roll-out
November 2025.
I hope that this letter provides both you and Mr Jervis’s family with assurance that the Trust has
taken seriously the matter of concerns you raised in your report and that the Trust has taken
appropriate action to prevent future deaths.
Yours Sincerely
Chief Medical Officer
Royal Cornwall Hospitals NHS Trust
Page 4 of 4
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