Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0205, written 16 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2025 |
|---|---|
| Reference | 2025-0205 |
| Deceased | Marina Raisbeck |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust 1 CORONER I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 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 9.11.23 , I commenced an investigation into the death of Mrs Marina May Raisbeck The investigation concluded at the end of the inquest on the 16th January 2025 The conclusion of the inquest was a narrative as follows: Marina Raisbeck, known as May, died from sepsis, secondary to a perianal abscess, on 7.11.23 at the Doncaster Royal Infirmary (DRI). Whilst initial treatment was provided for sepsis on admission to Bassetlaw District General Hospital (BDGH) on the evening of 4.11.23, there was a delay in her reaching BDGH on that day, and then there was a further delay in transfer to the DRI for planning of the necessary Incision and Drainage of the abscess. Over the hospital admission period, her kidney function worsened, and the necessary surgery to drain the abscess on 6.11.23, also had an impact on her physiological status. Whilst these issues of delay are serious, it is not possible to say that on balance they have caused or made a more than minimal, negligible or trivial contribution to her death, both because of the extent of her underlying frailty, and the seriousness of the infection that she faced. 4 CIRCUMSTANCES OF THE DEATH Marina May Raisbeck, known as May, died on 7.11.23, at the Doncaster Royal Infirmary, Doncaster, South Yorkshire. May was aged 82 at the time of her death. She had a number of significant chronic medical problems, that were being managed, including Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, (with a recent hospital admission), Chronic Kidney Disease, Ischaemic Heart Disease (leading to heart failure), and obstructive sleep apnoea. She also had morbid obesity. There was a RESPECT form in place from July 2023. May also had wound healing difficulties with leg and abdominal wounds managed by the District Nurse team. She was housebound, with an Exercise Tolerance of 5- 10 yards. May developed a red painful lump on her buttock at the end of October 23. She was seen on 1.11.23, and prescribed an antibiotic, Doxycycline. It is unclear whether this was prescribed for a possible chest or water infection. It was an unusual choice for a skin infection/evolving abscess. She was seen again on 3.11.23 and the abscess was clearly noted. It was not painful, but discharging. She was appropriately prescribed Flucloxacillin, and a District Nursing team referral made. There were no signs of sepsis on either of these occasions. On the morning of 4.11.23, she was seen by a District Nurse, who provided a dressing. No observations were taken at this appointment but May was not described as systemically unwell. Also on 4.11.23, the family had contacted the Out of Hours (OOH) service, 111, at 09.14 hours, as the 4th was a Saturday. A call back from a clinician from the Bassetlaw OOH GP service occurred at 15.27 hours- it is unclear what happened between the initial call, and the clinician call back, with May's daughter reporting a further call to the 111 service to follow up following the first call. The telephone assessment established that the abscess was now larger (5x5cm reported), and that it was red and painful. There was insufficient exploration of other systemic symptoms of infection, and this assessment should have resulted in a face to face assessment within 2 hours , rather than 6 hours as was arranged. May was then seen by a OOH GP at 19.51 hours on 4.11.23. May was identified as unwell at this point, though with normal temperature, pulse and blood pressure. This appropriately resulted in an ambulance transfer to BDGH, arriving at 21.13 hours. A nurse triage assessment followed at 21.49, where it was recognised May likely had sepsis- she now had a fever, with a low blood pressure of 95/39, a high breathing rate of 25 breaths per minute (though her breathing rate was often high at rest), pulse of 88/minute, just within the normal range. She was given a fluid bolus and IV antibiotics at 22.45, and a diagnosis of an abscess, requiring incision and drainage was made. She was accepted under the surgical team at the DRI (surgery not available at BDGH at the weekend), at 02,00am on 5.11.23. Thereafter, whilst May remained reasonably stable, her fluid balance was not recorded, and there was no repeat blood tests to monitor her lactate, and her kidney function, as should have occurred. She required two fluid boluses to improve her blood pressure, at 11.38 hours and 15.18 hours on 5.11.23 at BDGH. May was finally transferred to DRI on the evening of 5.11.23, and then incision and drainage were appropriately delayed until the morning of 6.11.23, as she was a high anaesthetic risk, and it was appropriate to delay until sufficient daytime staff were available. During surgery, which was completed appropriately, she had a period of 30-40 minutes of low blood pressure, despite treatment. Post operatively she remained drowsy. Over the subsequent 24 hours she developed worsening acute kidney injury. On the evening of 7.11.23 she had a cardiac arrest, and died shortly after. It is possible that earlier incision and drainage, on 5.11.23, would have led to a different outcome for May, but in light of her extensive medical issues leading to significant frailty, and the rapid progression of the perianal abscess leading to sepsis, despite appropriate treatment from the evening of 4.11.23, it is unlikely. There was no discussion between the Emergency Department medical team at BDGH, and the surgical team at the DRI, to consider prioritising May for transfer during 5.11.23, nor any agreed process for easy review of May's clinical parameters to again make an appropriate decision as to any need for more urgent transfer from BDGH to the DRI. 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. The lack of a system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital 2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital I am not reassured that necessary actions to address these serious issues identified are in place. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you 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 the 15th April 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 following Interested Persons: 1. The family 2. The Nottingham and Nottinghamshire Integrated Care Board 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 18th February 2025 Dr E. A. Didcock
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.
Interim Executive Medical Director , Medical Director - Operations , Associate Medical Director – Professional Standards , Clinical Governance & Professional Standards Co-ordinator (642149) 14 April 2025 STRICTLY CONFIDENTIAL – ADDRESSEE ONLY Dr E A Didcock Assistant Coroner Nottinghamshire Coroner Service The Council House Old Market Square Nottingham NG1 2DT Dear Dr Didcock Mrs Marina May Raisbeck (deceased) I write to you with respect to the Regulations 28 Report issued on the 18 February 2025 to the Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest into the death of Mrs Marina May Raisbeck concluded on the 16 January 2025. The report was received by the Chief Executive’s office and forwarded to me in order to provide a response. I have been assisted in constructing this response by and Quality and , Consultant Physician and Trust Sepsis Lead. Associate Chief Nurse for Patient Safety I would respond to the matters of concern referred to within the PFDR as follows: 1. The lack of system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital I would like to take this opportunity of assuring you and Mrs Raisbeck’s family that the Trust adheres to standards within Royal College of Emergency Medicine (RCEM) Guidance in that whilst waiting for specialty teams to respond to a referral, the patient in question remains the responsibility of the ED team, this includes reacting to changes in the patient’s clinical condition and investigation results. These professional standards are detailed within the roles and responsibilities of the Emergency Physician in Charge (EPIC). To enhance this standard, the Trust has immediately implemented a new initiative in Bassetlaw Hospital whereby every morning a Surgical Advanced Clinical Practitioner will undertake a face to face assessment of all surgical patients awaiting transfer to Doncaster Royal Infirmary in order to prioritise transfer. This assessment will include a full clinical review including monitoring blood tests. In terms of transfers, historically, transport from Bassetlaw Hospital has been booked only when a bed is available on the Doncaster site. The Trust’s transfer process has been reviewed and transport and bed will now be booked at the same time; with the expectation that the patient would be transferred to the next bed available. On the rare occasions that a bed is not available on arrival at the Doncaster site, the patient will be transferred to ED under care of the specialty team. We are in the process of reviewing the Trust’s Transfer Policy to reflect this change in practice. 2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital The Trust has successfully developed a tracking system which provides oversight to the host and receiving clinical teams and monitors the patient’s physiology parameters (including sepsis) and observations. It also enables clinical teams to prioritise patient care. This digital programme of work has already been rolled out in Acute Medicine and Paediatrics on both Bassetlaw and Doncaster Hospital sites to allow them to easily view all patients in the ED that have been referred to them. Discussions are nearing completion with our orthopaedic team to tailor the tracking system to reflect their standards of care and implementation is expected to be complete within 3-6 months. Meanwhile, further discussions with our wider specialties are commencing to implement the tracker for our surgical patients. The Trust is currently embarking on a full Digital Transformation programme and in particular the implementation of an Electronic Patient Record. In view of this, we need to prioritise digital programmes with limited resources and capacity. I trust that this will reassure you that the processes in ED around patients awaiting transfer have been made more robust as a result of the learning that has been generated through this Inquest and that the new arrangements put in place and planned will undoubtedly make it safer for patients who attend the department. Yours sincerely Acting Executive Medical Director Cc: , Chief Executive e, Associate Chief Nurse for Patient Safety & Quality
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