Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0030, 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 | 2025-0030 |
| Deceased | Denise Johnson |
| Coroner | Daniel Sharpstone |
| Coroner area | Suffolk |
| 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: 1 Trust 1 CORONER - The Chief Executive of East Suffolk and North Essex Foundation I am Daniel SHARPSTONE, Assistant Coroner for the coroner area of Suffolk 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 26th February 2024 I opened an Inquest into the death of: Denise Ellen Johnson The conclusion of the Inquest on 10th December 2024 was: Dee died from acute small and large bowel infarction secondary to necrotising pancreatitis and intraabdominal sepsis, both recognised complications of severe post ERCP pancreatitis, on the background of obesity, recent treatment for breast Cancer and severe psychological stress The medical cause of death was confirmed as: 1a Multi-organ failure 1b Severe E.coli septicemia 1c Pancreatic necrosis and ischemic bowel perforation 1d CBD stones and post ERCP pancreatitis 4 CIRCUMSTANCES OF THE DEATH Dee was admitted to hospital as an emergency with abdominal pain and jaundice on 13th August 2022. Dee was 42 years of age with a history of obesity, ongoing treatment for breast cancer and depression. Investigations revealed a gallstone in the common bile duct as the cause of her jaundice. An endoscopic retrograde cholangiopancreatography (ERCP) was performed and a plastic stent inserted for drainage. Dee became acutely unwell post ERCP and was diagnosed with acute necrotising pancreatitis. Dee was admitted to ITU for 9 days for supportive care and antibiotics. The care of Dee’s necrotising pancreatitis and associated peri-pancreatic collections via CT Scans, insertion of abdominal drains, treatment plans and clinical updates was managed at Ipswich General Hospital with ongoing advice and guidance from Addenbrooke’s Hepato- Pancreato-Biliary multidisciplinary team. Subsequent CT scanning showed severe pancreatitis with fat necrosis and peripancreatic Regulation 28 – After Inquest Document Template Updated 30/07/2021 fluid collections. Dee’s infected peri-pancreatic collections were drained by a series of drains. Dee had regular pain management, physiotherapy and dietician review. The peripancreatic collections were managed by ongoing abdominal drainage, flushing and antibiotics as guided by Microbiology. Despite ITU admission with intensive supportive care her condition deteriorated and Dee died on 24th November 2022. 5 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In these circumstances it is my statutory duty to report to you: MATTERS OF CONCERN Timely notification to ERCP practitioners following serious complications, with formal case review ERCP-based endoscopic complications should be presented in a formal setting in the presence of Endoscopy colleagues. There is a need for timely feedback to responsible ERCP practitioners in cases of procedure-based complications to ensure checks and learning on matters such as safety and adherence to guidelines and standard practice. Regular discussions about management plans and treatment options with NOK/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues Plans and management were discussed on the Surgical ward with Dee by the Consultant but there was a paucity of comprehensible and timely communication with the next of kin and rest of the family concerning management plans and treatment options. Two-way feedback in this situation plays a vital role in maintaining patient wellbeing and safety. Lack of clarity around named Surgical Consultant cover for unexpected leave It was unclear who was the Surgical Consultant responsible for Dee and her pancreatic disease management when her usual Consultant was off work due to unexpected leave. A clear handover process at Consultant Surgeon level for unexpected leave enables continuation of care between health care professionals and teams with continuity and oversight of treatment and management plans. Accordingly, I consider that: Not having timely notification to ERCP practitioners following serious procedure- based complications, and timely associated formal ERCP case review with endoscopy colleagues Not having regular explanations and discussions with NOK/family by the responsible Consultant concerning ongoing management plans and treatment options for inpatients with serious surgical issues and, Lack of clarity over named Surgical Consultant cover with responsibility for surgical inpatients during periods of unexpected leave Regulation 28 – After Inquest Document Template Updated 30/07/2021 All pose a significant risk to patient safety. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths as detailed above, and I believe you or your organisation have the power to take any such action you identify. 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 21, 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: 1. Dee’s next of kin. I am 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 30/12/2024 Daniel SHARPSTONE Assistant Coroner for Suffolk 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.
Mr Daniel Sharpstone Assistant Coroner for Suffolk Suffolk Coroners Service Beacon House Whitehouse Road Ipswich Suffolk IP1 5PB By Email Only Dear Mr Sharpstone Ipswich Hospital Heath Road Ipswich IP4 5PD 21 February 2025 Our Reference: REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF DENISE ELLEN JOHNSON WHICH CONLUDED ON 10 DECEMBER 2024 I write in connection with the above-mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 30 December 2024. I would like to take this opportunity to extend my condolences to Denise’s family for their loss. The Regulation 28 Report to Prevent Deaths issued by yourself on 30 December 2024 highlighted concerns relating to Ipswich Hospital, those concerns were expressed as follows: a. Timely notification to Endoscopic Retrograde Cholangio Pancreatography (“ERCP”) practitioners following serious complications, with formal case review; b. Regular discussions about management plans and treatment options with Next of Kin/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues; c. Lack of clarity around named Surgical Consultant cover for unexpected leave. The information presented below is intended to describe the actions which have been taken/are being taken at East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised. Timely notification to ERCP practitioners following serious complications, with formal case review The Trust’s endoscopy unit audit Post ERCP complications in an annual audit. Outpatient cases where complications develop are also audited and discussed at the Endoscopy governance meeting. The Trust’s endoscopy unit are now starting 3 monthly ERCP Multi-Disciplinary Team meetings, where all cases and complications will be discussed. Any inpatients who develop severe complications including pancreatitis, cholangitis, perforation or bleeding post ERCP, will be identified by the clinical team looking after the patient and notified to the endoscopy lead. The case will then discuss at the appropriate Multi-Disciplinary Team meeting to enable a formal case review. Regular discussions about management plans and treatment options with Next of Kin/family by a responsible Surgical Consultant for inpatients with serious chronic surgical issues The Trust understands the importance of open and continuing dialogue between consultants, patients and their families, to formulate the most appropriate management plan for that patient. The Trust is leading a patient and carer focus on improving the way we communicate with our patients. This includes new name badges for staff (including phonetic spelling of surnames if desired) and more consistent training on how to have honest, and consistent conversations. A new visitor’s charter is also being introduced in late Spring 2025 with extended visiting hours from 8am until 8pm each day which will bring greater access for patients, carers and families to talk to staff. The Trust is also implementing changes to ensure a named Consultant is allocated to patients, which will provide greater accessibly for patients and families to discuss treatment plans. Lack of clarity around named Surgical Consultant cover for unexpected leave A cross-site SOP has been drafted and approved since the Inquest entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant” which addresses cover for patients in the circumstance of unexpected consultant leave. We will embed this SOP within the surgical division. Learning from both the incident and the new SOP will be used to drive improvement Trust wide. I can also provide assurance that there will be a more general reminder to all colleagues of the availability of the on call consultant to respond to acute deterioration/concern should the named consultant be unavailable. I hope the above information demonstrates the learning and training that has been implemented to cover the concerns of the Coroner. I once again would like to extend my sincerest condolences to the family of Denise for their loss. If I can be of further assistance, please do not hesitate to contact me. Yours sincerely Chief Executive Officer East Suffolk & North Essex NHS Foundation Trust
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