Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0308, written 17 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 | 17 Jun 2025 |
|---|---|
| Reference | 2025-0308 |
| Deceased | Upali Meththananda |
| Coroner | Catherine Wood |
| Coroner area | North East Kent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Kent Hospitals University 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.
North East Kent Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: 03000 410502 Email: Date: 17 June 2025 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Cheif Executive, East Kent Hospitals NHS Trust 1. CORONER I am Ms. Catherine Wood Assistant Coroner for North East Kent 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 6 November 2023 I commenced an investigation into the death of Upali METHTHANANDA. The investigation concluded at the end of the inquest . The conclusion of the inquest was Narrative "He died as a result of bleeding from a severed blood vessel, a rare but recognised complication of thoracentesis. The hemorrhage occurred following the insertion of a chest drain to drain fluid from a left sided pleural effusion which arose as a complication of coronary artery bypass surgery for his underlying ischaemic heart disease." 1a Multi-Organ Failure 1b Hypovolemic Shock 1c Bleeding following thoracentesis (20 October 2023) for a pleural effusion following cardiothoraic surgery (3 October 2023) 1d II Chronic Lymphocytic Lymphoma, Cerebrovascular Accident (Stroke) in the Past 4. CIRCUMSTANCES OF THE DEATH Upali Meththananada was a 76 year old physiotherapist who despite his age was still working and active. He had a medical history of hypertension, ischaemic heart disease, chronic lymphocytic leukemia and previous stroke when he began to suffer from chest pain in early 2023. Coronary angiography revealed severe triple vessel disease and he was referred for coronary artery bypass surgery at St. Batholomew's hospital. He underwent surgery at St. Batholomew's on 3 October 2023 and his aorta was found to be heavily calcified so a decision was made to conduct the procedure without cardiopulmonary bypass. The procedure itself was complicated by bleeding and he required a number of blood products during surgery. He recovered following surgery but had a residual pleural effusion following removal of his chest drains but he was fit for discharge home when he left hospital on 10 October 2023. He presented by ambulance to the Queen Elizabeth the Queen Mother hospital with chest pain and shortness of breath on 17 October 2023 and was admitted to the Coronary Care unit. Imaging revealed a large left sided pleural effusion which was creating a midline shift and following discussions with his earlier treating cardiologist, treating cardiothoracic surgeon and the cardiologist at Queen Elizabeth the Queen Mother hospital a decision was made to perform a chest drain locally. The chest drain was inserted on the afternoon of 20 October 2023 at around 14.30 -15.00 and 700mls of blood stained fluid drained before the drain was removed. He was initially stable but following the insertion he collapsed with signs of hypovoleamia at 15.45 . An emergency call was initiated and help summonsed and attempts were made to correct his hypovolemia using blood products and drugs and discussions held with the team at St. Batholomew's about transferring him. He remained unstable and at around 18.15 suffered from a cardiorespiratory arrest and despite continued attempts at resuscitation including a thoracotomy to stem any bleeding he died at 19.40. 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) I was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse. Clinical observations were not documented, meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians. Whilst I heard some improvements had been made by the witness who presented the Trust's action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you the Chief Executive at East Kent Hospitals NHS Trust 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 13 August 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 Mr. Meththanada's family and Barts NHS Trust. 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 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. 17 June 2025 Signature Catherine Wood Area Coroner for North East Kent
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.
NHS East Kent Hospitals University NHS Foundation Trust Chief Executives Office Trust Offices Kent & Canterbury Hospital Ethelbert Road Canterbury Kent CT1 3NG North East Kent Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE By email only: kentandmedwaycoroners@kent.gov.uk; 13 August 2025 Dear Ma’am, RE: East Kent University Hospitals NHS Foundation Trust (The “Trust”) response to Regulation 28 received on 17June 2025 in relation to the case of Mr Upali METHTHANANDA. | write in response to the Regulation 28 report the Trust received at the conclusion of the inquest into the death of Mr Meththananda. The Trust would like to extend their condolences once again to the family of Mr Meththananda. The Trust wishes to reassure the coroner and the family that significant learning has taken place from this case and we are committed to improving our IT infrastructure to ensure patient safety is optimised At the inquest you stated that you were concerned about the following: ! was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst | accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse. Clinical observations were not documented, meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians. Whilst | heard some improvements had been made by the witness who presented the Trust's action plan | remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future. Our response to your concern and the actions the Trust has taken are explained below: As part of our commitment to continually review and improve quality we recently undertook a trust wide audit supported by our Clinical Audit and Improvement Team of documentation across the organisation in all representative care settings. This highlighted a number of areas for improvement of both digital and written documentation which will be presented to our Operational Quality Governance Committee for support and communication across Care Groups. Following this ongoing documentation audits will be planned within Care Groups to monitor quality and progress in improvement. Specifically, within the digital setting of documentation a number of actions have or will be completed: o Gemba walks were conducted across the emergency and inpatient settings on the 3 July and 1 August at Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate. A Gemba walk is a walk through of the clinical environment for senior leaders to review how processes are working in real time at the point of care to see for themselves where issues are arising. Actions are then set to follow up on these issues and improve the interface between patient care and note taking. o Following feedback from the Gemba walks, additional IT Technical Team walks of the emergency and inpatient settings along with the Clinical IT Team will be undertaken in August to review the current IT hardware across settings. We will review provision, accessibility and reliability of hardware to ensure clinical teams have access to the right technology at the point of care to facilitate and encourage real-time documentation and recording of clinical parameters and observations. o We are waiting for our Electronic Medical Record (EMR) supplier to install an improved trend charting which will allow clearer visibility of trends in specific observation parameters over time (i.e. 24 hours/12 hours). This should be installed by the end of September 2025. o Acommunication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting’ within the digital clinical notes. o A trial will begin in the Surgical Teams at QEQM in August with the use of the ‘Sunrise Mobile’ (Sunrise™ - EKHUFT Electronic Medical Record (EMR)) application on a tablet device to assess whether this can facilitate more real-time documentation at the point of care to improve the quality of documentation in an acute setting by providing an easier and more portable hardware device over a computer on wheels. o The digitisation of the surgical care plan documentation is being planned and along with this a review of Local Safety Standards for Invasive Procedures (“LocSSIP’s”) to plan digitisation. This will ensure they are always visible in the medical record and drive compliance with documentation through mandating where appropriate data entry. We will continue to review these plans and re-audit to ensure that improvements are being made. Yours-sincerel Chief Executive Officer
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