Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 26 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Sep 2018 |
|---|---|
| Deceased | Angela Jackson |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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:
1. The Right Honourable Matt Hancock MP, Secretary of State for Health,
Department of Health and Social Care, 39 Victoria Street,
London SW1H 0EU
2. Ms Karen Partington, The Chief Executive, Lancashire Teaching Hospitals
NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane,
Fulwood, Preston PR2 9HT
3. Sir Michael Deegan CBE, The Chief Executive, Manchester University
NHS Foundation Trust, Cobbett House, Manchester Royal Infirmary,
Oxford Road, Manchester M13 9WL
4. Ms Jane Tomkinson OBE, The Chief Executive, Liverpool Heart and Chest
Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE
1
CORONER
I am Alan P Walsh, Area Coroner for the Coroner Area of Manchester West.
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 the 9th April 2018 I commenced an Investigation into the death of
Angela Mary Jackson, 81 years, born on the 29th May 1936.
The Investigation concluded at the end of the Inquest on the 11th
September 2018.
The medical cause of death was:-
Ia Ruptured Thoracic Aortic Anyresum
The Conclusion of the Inquest was Natural Causes.
4
CIRCUMSTANCES OF THE DEATH
1. Angela May Jackson (hereinafter referred to as “the Deceased”) died at
the Royal Albert Edward Infirmary, Wigan on the 31st March 2018.
1
2. On the 29th March 2018 the Deceased was admitted to the Emergency
Department at the Royal Albert Edward Infirmary, Wigan (hereinafter
referred to as “the Wigan Hospital”) at approximately 11.20 hours with
a 3 day history of right lower chest and upper quadrant abdominal pain.
A CT pulmonary angiogram excluded a pulmonary embolism but
identified a 9.5cm descending thoracic aortic aneurysm, the aneurysm
extended to the abdomen and in addition the arch of the aorta above
the descending thoracic anyreusm was also aneurysmal. Essentially the
process involved most of the aorta but there was no evidence of
rupture of the anyreusm.
3. At or about 20.04 hours on the 29th March 2018 a doctor from the
Wigan Hospital referred the Deceased to the Vascular Surgery
Department at the Royal Preston Hospital, (hereinafter referred to as
“the Preston Hospital”) and the Preston Hospital advised that the scans
would be reviewed and “arranged for transfer”. When there was no
response from the Vascular Surgeons at the Preston Hospital, a doctor
from the Wigan Hospital telephoned the Vascular Registrar on call at
the Preston Hospital at 11.33 hours on the 30th March 2018 and the
Registrar at Preston confirmed that the Deceased would be discussed
with the Interventional Radiologist at a Multi-Disciplinary Team meeting
later that day.
to contact
the Wigan Hospital was advised
At 16.30 hours the Vascular Registrar from the Preston Hospital
telephoned the Wigan Hospital and left a message that the Multi-
Disciplinary Team recommendation was to refer the Deceased to a
Cardiothoracic Centre where such aneurysms might be considered for
repair and
the
“Wythenshawe Cardiothoracic Team”, which was the Cardiothoracic
Team at Whythenshawe Hospital, Manchester (hereinafter referred to
as
“the Wythenshawe Hospital”). The Cardiothoracic Surgery
Department at the Wythenshawe Hospital is a Consultant led service
and at 20.05 hours on the 30th March 2018 the Consultant advised that
a descending thoracic aneurysm (as opposed to an ascending aortic
aneurysm or dissection) was not routinely dealt with by them and, if the
patient required an urgent surgical repair, such repairs should be
managed by the regional Aortic Centre at Liverpool and a doctor at the
Wigan Hospital was advised to refer the Deceased to the Liverpool
Heart Centre.
4. The Liverpool Heart Centre is actually the Liverpool Heart and Chest
Hospital (hereinafter referred to as “the Liverpool Hospital”).
Between 01.30 hours and 02.00 hours on the 31st March 2018 a doctor
from the Wigan Hospital contacted a doctor from the Liverpool Hospital
and spoke to the Cardiology Registrar on call at the Liverpool Hospital.
The Registrar at Liverpool Hospital informed the Wigan doctor that he
was referring the patient to the wrong speciality and advised him to
speak urgently with an Aortic Surgeon, either Vascular or
Cardiothoracic. The Registrar gave evidence at the Inquest that the
Liverpool Hospital had three main departments, namely Cardiothoracic
Surgery, Cardiology and Respiratory Medicine but he did not offer to
2
connect the doctor from the Wigan Hospital to the Cardiothoracic
department and he did not give details of the three separate
departments, except to say that the doctor had contacted the wrong
speciality.
In view of the fact that the Registrar advised the Wigan doctor to speak
urgently with an Aortic Surgeon, either Vascular or Cardiothoracic, the
Wigan doctor contacted the Preston Hospital again to speak to a
Vascular Surgeon. The Preston Hospital was contacted at 02.27 on the
31st March 2018 and the Registrar at the Preston Hospital confirmed
that the referral would be discussed with the Consultant and the
Preston Hospital would contact the Wigan Hospital following that
discussion.
5. At or about 02.37 hours the Deceased became clammy and reported
pain as pleuritic type right sided pain and the Wigan doctor contacted
the Preston Hospital who informed him that the Deceased was not for
Vascular input and the doctor should contact a Cardiothoracic Surgeon.
At that time the Deceased was stable and it was decided that there
would be further discussions with the Cardiothoracic Surgeon later in
the morning.
6. At approximately 04.00 hours the Deceased suffered a cardiac arrest
following and she died.
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. During the Inquest evidence was heard that:-
i. The treatment of an aortic aneurysm depends on the position of the
aneurysm. In general terms aneurysms above the diaphragm are
referred to as thoracic aneurysms and should be treated by
cardiothoracic surgeons and aneurysms below the diaphragm are
referred to as abdominal aneurysms and should be treated by
vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon
may also depend on the position of the aneurysm above the
diaphragm. An ascending thoracic aneurysm could be dealt with by
local Cardiothoracic Surgeons at the Wythenshawe Hospital in
Greater Manchester, whereas a descending thoracic aneurysm
should be referred to and managed by the Regional Aortic Centre in
Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the
Liverpool Heart Centre and advised the Wigan Hospital to contact the
3
Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not
exist and the correct referral should have been to the Liverpool Heart
and Chest Hospital.
iii. There are no written protocols or pathways in relation to the
treatment of aortic aneurysms in Greater Manchester or the North
West of England, although the Preston Hospital has started to
prepare a written Acute Aortic Syndrome Pathway. However, the
Acute Aortic Syndrome Path is only in draft form, which has not been
approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of
aortic aneurysms is a national problem, which needs to be addressed
to enable local district hospitals to be aware of the pathway and to
have clear, unequivocal direction for referral of patients with
appropriate and correct lines of referral, including the correct names
of hospitals and direct telephone numbers and email addresses to
ensure efficient and expedient referrals to appropriate hospitals and
appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in
many cases, requires an urgent referral and emergency treatment
and in my opinion there is a risk that future deaths will occur unless
action is taken to consider clear and unequivocal pathways for the
referral of patients requiring such treatment.
2.
3.
I request the Trusts governing the Preston Hospital, the Wythenshawe
Hospital and the Liverpool Hospital to review the referral systems and
to consider clear and unequivocal documented pathways for the
treatment of patients with aortic aneurysms and the distribution of such
documented pathways
to district Hospitals and all healthcare
professionals within the areas serviced by their Hospitals.
I request the Secretary of State for Health to review guidance and
direction given to all vascular surgery and cardiothoracic surgery
departments in the United Kingdom in relation to the referral and
treatment of patients with aortic aneurysms, with particular reference to
clear and unequivocal documented pathways as referred to above.
6
ACTION SHOULD BE TAKEN
In my opinion urgent action should be taken to prevent future deaths and I
believe that 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 Monday 19th November 2018. 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
4
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.
, Mrs Jackson’s granddaughter,
,
2. Mr Andrew Foster CBE, Chief Executive, Wrightington, Wigan and Leigh
NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane,
Wigan WN21 2NN
3.
, Solicitor, Wrightington, Wigan and Leigh NHS
Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan
WN21 2NN
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.
9
Dated
Signed
26th September 2018
Alan P Walsh-
HM Area Coroner
5
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