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 | John Waite |
| 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.
3.
4.
, President, The Renal Association, 3rd Floor, Learning
and Research Building, Southmead Hospital, Southmead Road, Bristol
BS10 5NB
Wharf, Davidson Road, Lichfield, Staffordshire WS14 9DZ
, President, British Renal Society, EBS Ltd., City
35 Red Lion Square, London WC1R 4SG
, President, Intensive Care Society, Churchhill House,
5. Sir David Dalton, The Chief Executive, Salford Royal NHS Foundation
Trust, Stott Lane, Salford M6 8HD
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 22nd March 2018 I commenced an Investigation into the death of
John Waite, 74 years, born on the 21st November 1943.
The Investigation concluded at the end of the Inquest on the 10th
September 2018.
The medical cause of death was: -
Ia Haemorrhage from removal of Femoral Dialysis Line, Pneumonia and
Acute Kidney Injury due to Rhabdomyolysis.
II
Ischaemic Heart Disease, Hypertensive Heart Disease and Prophylactic
Anti-Coagulation.
The conclusion of the Inquest was that John Waite died as a consequence of
1
a combination of Pneumonia and Acute Kidney
to
Rhabdomyolysis arising from a long period of time on the floor following an
accidental fall, and a Haemorrhage due to a rare but recognised
complication of the removal of a Femoral Dialysis Line inserted for the
treatment of the Acute Kidney Injury exacerbated by a recognised
complication of Prophylactic Anti-Coagulation treatment on a background of
naturally occurring disease.
Injury, due
4
CIRCUMSTANCES OF THE DEATH
1. John Waite (hereinafter referred to as “the Deceased”) died at the
Salford Royal Hospital, Eccles Old Road, Salford on the 11th March 2018.
2. On the 25th February 2018 the Deceased, who suffered with naturally
occurring Ischaemic Heart Disease and Hypertensive Heart Disease, had
,
a fall in the bedroom at his home address at
. He lay on the bedroom floor for a considerable period of time
following the fall before his family found him. He was taken to the
Royal Albert Edward Infirmary, Wigan, where he was treated for
Rhabdomyolysis with hemofiltration and for Pneumonia with antibiotics.
3. The Deceased required ongoing renal replacement therapy and, on the
6th March 2018, he was transferred to the Salford Royal Hospital,
Salford for such therapy.
4. On the 7th March 2018 a right femoral vein dialysis line was inserted as
a central venous catheter for haemodialysis treatment and during his
time in hospital the Deceased received prophylactic anticoagulation
treatment.
5. On the 11th March 2018, the central venous catheter was removed, in
accordance with hospital protocols, to prevent infection. At the time
the Deceased was the sole occupant of a side room on H3 Ward at the
Salford Royal Hospital and the central venous catheter was removed by
a Nurse Practitioner in the side room at an uncertain time between 12
noon and 13:00 hours.
Following the removal of the central venous catheter, the Nurse
Practitioner applied pressure to the site of the catheter for a period of
15 minutes and she sat the Deceased up to a 40-degree angle to
enable him to have something to eat. The Nurse Practitioner assisted
the Deceased for a few minutes whilst she cut a sandwich for him and
to check if he could manage. She left him on his own in the side room
whilst he started to eat the sandwich and she left a buzzer next to his
left hand. The Nurse Practitioner closed the door behind her when she
left the room, as the Deceased was being barrier nursed for infection
and the infection control policy required the door to remain closed at all
times for infection precautions. The Nurse Practitioner left the side
room at approximately 13:10 hours and the Deceased was left on his
own in the room at that time.
6. At or about 13:40 hours a Physiotherapist entered the side room for the
2
purpose of a new patient mobility assessment and when she entered
the room she noticed large amounts of blood on the floor covering
halfway down the length of the right side of the bed, being the side
where the central venous catheter had been removed, and spreading
across the floor approximately half a metre out from the side of the bed.
The blood had also spread through a sheet and a blanket on the bed in
the area where the central venous catheter had been removed. She
noticed that the patient was sat up in bed at the time and she
completed an emergency crash call on the basis that the Deceased had
suffered a cardiac arrest.
The Physiotherapist made a note of the incident in the electronic
hospital notes. The author time of the note was recorded as 13:40
hours and the update of the note was recorded as completed at 14:36
hours. The Physiotherapist admitted that she had changed the author
time on the electronic system and she confirmed that the electronic
system allowed for such a change to take place. She gave evidence that
she changed the author time of the note to accord with the time she
entered the side room, instead of the time that she authored or made
the note.
7. When the cardiac arrest call was made, the cardio arrest procedure
commenced immediately but resuscitation was not successful and the
Deceased died at 14:08 hours on the 11th March 2018.
CORONER’S CONCERNS
During 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. A haemorrhage following the removal of a central venous catheter is
a rare, but known, complication of the removal of a central venous
catheter and the complication has never been seen by many
experienced Renal Physicians, including the 3 Renal Physicians giving
evidence at the Inquest.
ii. The Central Venous Catheter Insertion Management and Removal
Policy for Short Term Catheters in existence within the Salford Royal
NHS Foundation Trust at the time of the death included the fact that
pressure should be applied for approximately 5 minutes after
removal of the catheter or until bleeding has stopped and a patient
should lie flat or supine for 30 minutes after removal of the catheter
(if medically safe to do so). The guidelines did not state that a
patient requires visual observation for a period of time following the
removal of the catheter.
iii. Following the death of the Deceased the Salford Royal NHS
3
Foundation Trust has taken action to address the concerns in relation
to the Central Venous Catheter Insertion Management and Removal
Policy for Short Term Catheters, together with the ongoing training
of staff who undertake the removal of catheters and the
management of rare complications.
A quick reference guide has been issued to staff by the Hospital in
relation to the removal of catheters at the Hospital. The guide
requires the patient to remain supine for 30 minutes post removal of
the catheter with further bed rest for 2 hours post removal and a
visual inspection of the dressing every 5 minutes during the period of
1 hour following the removal. However, the guide does not require
constant visual observation for a period of time following the
removal of the catheter.
The evidence at the Inquest was that, if there is haemorrhage
following the removal of a catheter, blood loss could amount to
200mls every minute so that in the period of 5 minutes between
each 5-minute inspection of the dressing, advised by the guidance,
one litre of blood could be lost, which could lead to death.
The evidence at the Inquest was that a period of constant visual
observation is required for a period of up to one hour following the
removal of a catheter to reduce the risk of blood loss rather than
simply monitoring by inspecting the dressing every 5 minutes for
that period of time.
iv. There are no national guidelines in relation to the removal of central
venous catheters, particularly temporary central venous catheters for
haemodialysis. The evidence at the Inquest confirmed that the
Secretary of State, the Renal Association, the British Renal Society
and the Intensive Care Society would be appropriate organisations to
consider the issue of a national policy, protocol and guidance relating
to the removal of central venous catheters.
v. The evidence of the Physiotherapist in relation to changing the
author times of notes on the central computer note system at the
Salford Royal NHS Foundation Trust was not believed to be possible
by representatives of the Hospital Trust attending the Inquest but
the Physiotherapist was adamant, in her evidence, that she changed
the times, which was her usual procedure, so that the author time
recorded by her represented the time of the action taken by her
rather than the time of the note made by her.
2.
I request the Secretary of State for Health, the Renal Association, the
British Renal Society and the Intensive Care Society to review the
policies and protocols in relation to the removal of central venous
catheters and to consider the issue of national guidelines relating to the
removal of catheters. The review should consider the constant visual
observation of a patient for a period of one hour following the removal
of the catheter, particularly in view of the extent of blood loss which
4
may arise if a patient is left on their own for periods of 5 minutes
following the removal of the catheter.
3.
I request the Salford Royal NHS Foundation Trust to further review the
policy and protocols together with the quick reference guide to consider
the constant visual observation of a patient for a period of one hour
following the removal of a central venous catheter to prevent extensive
blood loss and to prevent future deaths.
I acknowledge that a considerable amount of work has been done by
the Salford NHS Foundation Trust, but I request a further review to
cover the above matters of concern.
4.
I request the Salford Royal Hospital to review their information
technology systems to prevent the changing of author times of notes on
the electronic system because the author times can represent an
important time in relation to the treatment and care given to a patient
and may be relied upon by healthcare professionals who give treatment
and care after the time of a note. The review should also consider
whether both the time of the author of the report and the time that
appropriate action is taken should be included in the note so that
healthcare professionals would have to record both times when
completing notes to ensure that there is unequivocal clarity as to the
time the action was taken and the time the note was authored.
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 Wednesday 21st 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
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.
Mr Waite’s daughter, 4
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
5
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
6
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.