Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2026-0272, written 12 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jun 2024 |
|---|---|
| Reference | 2026-0272 |
| Deceased | Beryl Dandridge |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Organisation named | Oxford University Hospitals NHS Foundation Trust |
| Source | judiciary.uk record |
| 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Oxford University Hospitals NHS Foundation Trust 1 CORONER I am Nicholas Graham, HM Area Coroner for Oxfordshire, c/o Oxfordshire Coroner’s Office, 1 Tidmarsh Lane, Oxford OX1 1NS 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 6 February 2024 I commenced an investigation into the death of Beryl Dandridge, aged 83. The investigation concluded at the end of the inquest on10 June 2024. The conclusion of the inquest was a Narrative Conclusion: ‘On the 23 January 2024 Beryl Dandridge had a fall at her nursing home injuring her hip. An ambulance was called but due to demand it took over 12 hours to attend. She was taken to the John Radcliffe Hospital, Oxford and it was identified that she had suffered a periprosthetic fracture. She was originally listed for surgery on the 25 January, but other cases took priority. She was then re-scheduled for surgery on the 26 January, but this was postponed as it was considered she needed an echocardiogram to assess the potentially fatal risk of surgery. Her surgery took place on the 27 January. Following surgery her condition deteriorated and she died on the 28 January 2024. There is insufficient evidence to establish whether the combined delay in her admission to hospital and in undergoing surgery contributed to her death.’ 4 CIRCUMSTANCES OF THE DEATH Please see the Narrative Conclusion in paragraph 3 above which outlines the circumstances. Upon arrival at the hospital, medical staff noted Mrs Dandridge's high heart rate, which was attributed to atrial fibrillation. She underwent surgery for her fractured femur on 27 January, after delays due to theatre capacity issues and differing opinions among medical staff regarding the necessity of a pre-operative echocardiogram. Mrs Dandridge's condition deteriorated after surgery, and she died the following morning. There were concerns raised about the delays in her surgery and the arrangements for expediting an echocardiagram. A Structured Mortality Review was undertaken on the 7 February 2024 which was critical of the anaesthetist’s decision to require an echocardiogram prior to surgery and the lack of expedition. 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 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. – 1. As part of the evidence, it became clear there were conflicting views between clinicians regarding the need for an echocardiogram for vulnerable patients pending periprosthetic surgery and the circumstances when surgery might be appropriately delayed pending such a scan. Evidence was heard that the Anaesthetists of Great Britain and Ireland (AAGBI) guidelines regarding echocardiograms (which apply to hip surgery more generally) were incorrectly applied to the circumstances of Mrs Dandridge’s periprosthetic fracture. 2. Having determined that an echocardiogram was required before surgery could take place, it was unclear which clinicians was responsible for expediting such a scan in circumstances where the evidence indicated that delays in surgery is associated with poorer outcomes for vulnerable patients. 3. The Structured Mortality Review was critical of the decision to require an echocardiogram pending surgery. Such a review is designed to provide learning for the Trust to be applied in future cases. The evidence at the Inquest was that the Review had no input from an anaesthetist who may have articulated the medical justification for such an echocardiogram in this instance. Concerns were raised in evidence that without the relevant subject expertise at such Reviews any future learning from a Structured Mortality Review could be inaccurate or misconceived. You should consider a review of your procedures relating to the arrangements for echocardiograms and to the conduct of structured mortality reviews. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 6 August 2024. 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 Mrs Dandridge’s family. I have also sent it to Dr Joanne Cudlipp, who was an Interested Person, who may find it useful or of interest. I have also sent a copy to the Berkshire, Buckinghamshire and Oxfordshire 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 other 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. 9 12 June 2024
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.
INHS} Oxford University Hospitals NHS Foundation Trust The John Radcliffe Hospital Trust Headquarters Academic Centre Headley Way Headington Oxford OX3 9DU 22 July 2024 PRIVATE AND CONFIDENTIAL Mr Nicholas Graham HM Area Coroner for Oxfordshire Dear Mr Graham Following the death of Mrs Beryl Dandridge, and subsequent inquest hearing on 10 June 2024, | write as CEO of Oxford University Hospitals NHS Foundation Trust (OUH), to provide a response to your Regulation 28 Report dated 12 June 2024. | would like to start by expressing to Mrs Dandridge’s family how sorry | am for their loss. Mrs Dandridge underwent a surgical repair of a periprosthetic fracture (a fracture associated with a previous orthopaedic knee implant) of the left distal femur at the John Radcliffe Hospital on 27 January 2024. You recorded a narrative conclusion which states ‘There is insufficient evidence to establish whether the combined delay in her admission to hospital and in undergoing surgery contributed to her death.” The cause of death was: 1a) ST elevation Myocardial Infarction 1b) Penprosthetic distal femur fracture 2) Dementia, Atrial Fibnilation, heart failure, chronic kidney disease Prior to the inquest hearing, the Trust's Structured Mortality Review (Ulysses ID 353853) dated 7 February 2024 was disclosed to your office which had been discussed at the Trust's Mortality Review Group, on 18 April 2024. You set out the following areas of concern: 1. Application of the most appropriate clinical guidelines 2. Description of the process for obtaining an urgent echocardiogram. 3. Assurance that OUH Mortality Review process includes a clinician with the relevant subject expertise. We reviewed these points and convened a Learning Multi-disciplinary Team meeting and response under the Patient Safety Incident Response Framework (PSIRF): 1. Application of appropriate Clinical Guideline The Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines on the management of hip fractures (2020) are not explicitly for the type of fracture that Mrs Dandridge experienced (distal peri-prosthetic femur fracture). However they are used as a guide for all fragility femoral fractures by the Orthogenatrician Team. We convened a group of experts at the Learning Multi-disciplinary Team meeting including the Orthogeriatrician team and the Anaesthetist involved in this case and have agreed that whilst the same principles of the AAGBI guidelines apply to patients with periprosthetic fractures as to other femoral fragility fractures, these cases present a more complex risk / benefit analysis due to the increased length of operation and complexity of the surgery and therefore each patient will require an individualised risk assessment. 2. OUH urgent Echo-Cardiogram request process We already have a process for requesting urgent echocardiograms within the Trust. This process was reviewed and clarified at the Learning Multidisciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant Cardiology team and the escalation will go through the on call Consultant Cardiologist. Some members of the Orthogeriatrics team will also undergo training in focused bedside echocardiography to provide further capacity for urgent echocardiograms. 3. OUH Mortality Review Process The OQUH Mortality Review Process includes dedicated training for senior clinicians in conducting Structured Mortality Reviews (SMR). SMRs are presented to the Trust Mortality Review Group which is composed of a range of consultants. The SMR discussion for this case did involve an anaesthetist when it was presented at MRG. We have strengthened the SMR training, guidance and report template to include a requirement to discuss any concerns about poor clinical care raised in the SMR with the appropriate clinician involved and to include their views within the SMR as necessary. The Mortality Review Group will ensure that subject matter expertise is included in all cases, especially where there are concerns about the quality of care provided and if necessary a wider Learning MDT meeting with a range of subject matter experts will be convened to explore any differences of opinion. The learning from this case will be presented at the Trust Safety Leaming and Improvement Conversation (SLIC) meeting, the Trust Mortality Review Group, and the Clinical Governance meetings for Anaesthetics, Trauma and Orthogeniaatrics. | hope that this response will reassure you that we have taken your concerns very seriously and worked quickly to implement appropriate changes to our processes as a result of this inquest. Yours sincerely le} ecutive cer
See every Prevention of Future Deaths report matching Oxford University Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.