Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0272, written 3 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2025 |
|---|---|
| Reference | 2025-0272 |
| Deceased | Esther Byrne |
| Coroner | Janine Richards |
| Coroner area | Durham and Darlington |
| Category | Care Home Health related deaths · 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 1 CORONER I am Janine RICHARDS, Assistant Coroner for the coroner area of County Durham and Darlington 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 30/12/2024 14:54an investigation was commenced into the death of Esther Jane Lancaster BYRNE 06/02/1932 00:00:00. The investigation concluded at the end of the inquest on 02/06/2025 00:00. The conclusion of the inquest was that Esther Jane Lancaster Byrne, aged 92 years, died at her care home on the 18th of December 2024. The deceased had a diagnosis of vascular dementia and was extremely frail. She deteriorated subsequent to an accidental fall which occurred on the 1st of November 2024 when she sustained a neck of femur fracture, which in the light of her frailty and some doubt as to the presence a fracture or whether this was, in fact, an osteophyte curtain, by the treating physician, was treated conservatively. The deceased was readmitted on the 4th of December 2024 due to increased hip pain and when the fracture sustained had become displaced, possibly due to a further fall. This was operated upon on the 5th of December 2024 and the deceased was discharged back to her care home and subsequently deteriorated to her death.. 4 CIRCUMSTANCES OF THE DEATH Esther Jane Lancaster Byrne, aged 92 years, died at her care home on the 18th of December 2024. The deceased had a diagnosis of vascular dementia and was extremely frail. She deteriorated subsequent to an accidental fall which occurred on the 1st of November 2024 when she sustained a neck of femur fracture, which in the light of her frailty and some doubt as to the presence a fracture or whether this was, in fact, an osteophyte curtain, by the treating physician, was treated conservatively. The deceased was readmitted on the 4th of December 2024 due to increased hip pain and when the fracture sustained had become displaced, possibly due to a further fall. This was operated upon on the 5th of December 2024 and the deceased was discharged back to her care home and subsequently deteriorated to her death. 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) Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan. 2. There were numerous discrepencies in the evidence demonstrating a misunderstanding by various medical staff as to the deceased's baseline presentation, and the extent to which she had or had not mobilised whilst an inpatient which were pertinent to care planning upon discharge and to any handling required to be risk managed by the care home. 3. It was accepted that a follow up appointment should have been arranged for the deceased after discharge and there was no explanation for why this was not arranged. 4.The treating consultant physician expressed considerable doubt as to the quality and accuracy of radiological reporting provided by the outsourced out of hours service (which is understood to be outside the UK) and accepted that this issue, amongst others, contributed to his doubt that the deceased had sustained a fracture. The Inquest heard that there was no ability to discuss the findings with the reporting radiologist. 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 July 29, 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 have also sent it to who may find it useful or of interest. 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: 03/06/2025 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Janine RICHARDS Assistant Coroner for County Durham and Darlington 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.
www.cddft.nhs.net Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX E-mail: Our Ref: 25th July 2025 Janine Richards, Assistant HM Coroner, County Durham Dear Ms Richards, Re: Esther Byrne We are writing in response to your request for the Trust to take action in relation to concerns as detailed below: (1) Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased’s baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan. (2) There were numerous discrepancies the evidence demonstrating a misunderstanding by various medical staff as to the deceased’s baseline presentation, and the extent to which she had or had not mobilised whilst an inpatient which were pertinent to care planning upon discharge and to any handling required to be risk managed by care home. in (3) It was accepted that a follow up appointment should have been arranged for the deceased after discharge and there was no explanation for why this was not arranged. (4) The treating consultant physician expressed considerable doubt as to the quality and accuracy of radiological reporting provided by the outsourced out of hours service (which is understood to be outside the UK) and accepted that this issue, amongst others, contributed to his doubt that the deceased had sustained a fracture. The Inquest heard that there was no ability to discuss the findings with the reporting radiologist. The Trust would like to offer its sincere condolences to Ms Byrne’s family for their loss. We take very seriously the concerns which you have raised and have provided a response below. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased’s baseline presentation www.cddft.nhs.net which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan. On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review. There were numerous discrepancies the evidence demonstrating a misunderstanding by various medical staff as to the deceased’s baseline presentation, and the extent to which she had or had not mobilised whilst an inpatient which were pertinent to care planning upon discharge and to any handling required to be risk managed by care home. in Communication failures resulted in conflicting information regarding mobility status and the ability to transfer from bed to chair. On 4th November and 6th December 2024, Ms Byrne’s baseline mobility was documented as having the ability to walk short distances with a wheeled Zimmer frame with supervision in the care home. This information was provided by the care home staff and the patient’s granddaughter. On the 5th November 2024, the patient was only able to transfer from the bed to chair with assistance of 2 staff and using a wheeled Zimmer frame. During the patients second admission hospital (3rd December 2024) Ms Byrne was not able to stand with assistance and the plan was to nurse in bed/hoist. Although there was a plan for the patient to be discharged back to her care home, the physiotherapists were planning to complete further mobility assessments including considering using a hoist for transfers. Unfortunately this assessment did not take place prior to Ms Byrne’s discharge back to the care home. The patient had not returned to her baseline level of mobility and therefore a further discussion with the family care home should have taken place to ensure the care home could meet Ms Byrne’s care needs. As a result of this the ward has made adjustments to ensure the physiotherapy team attend orthopaedic ward rounds and have access to electronic clinical records to ensure they are involved in decision making and contribute to discussion regarding the mobility status of patients. As a further action physio and occupational therapist will input to patient’s discharge letter to record patients mobility status. It was accepted that a follow up appointment should have been arranged for the deceased after discharge and there was no explanation for why this was not arranged. The accountable doctor, accepts that the lack of a scheduled follow up appointment was an error on his part. A discharge process is in place to include scheduling a follow up appointment for every patient (if required) and confirmation is documented in the patient records. To ensure compliance with this process regular ward audits will be completed to provide assurance. The treating consultant physician expressed considerable doubt as to the quality and accuracy of radiological reporting provided by the outsourced out of hours service (which is understood to be outside the UK) and accepted that this issue, amongst www.cddft.nhs.net others, contributed to his doubt that the deceased had sustained a fracture. The Inquest heard that there was no ability to discuss the findings with the reporting radiologist. The Trust acknowledges that there may be occasions when contacting the out-of-hours radiologist proves challenging. In such cases, the duty radiologist should be contacted as the next point of escalation. To ensure all clinical teams are fully informed of this protocol, a flow chart detailing the contact process has been circulated. This has also been shared directly with the orthopaedic consultants to support consistent application across relevant departments. Conclusion We trust that the responses detailed in this letter are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries. Yours sincerely Executive Director of Nursing Executive Medical Director cc. , CEO , Associate Director of Nursing, Patient Safety and CNIO
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