Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 11 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2018 |
|---|---|
| Deceased | Paliben Dullabh |
| Coroner | Sarah Bourke |
| Coroner area | London Inner (North) |
| 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.
Coroner ME Hassell
HM Senior Coroner
Inner North London
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Martin Kuper
Medical Director
Homerton University Hospital
Homerton Row
London
E9 6SR
1
CORONER
I am: Assistant Coroner Sarah Bourke
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
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 19 October 2017, Senior Coroner Mary Hassell commenced an investigation
into the death of Paliben Dullabh (87 years). The investigation concluded at the
end of the inquest which was conducted by me on 11 October 2018. The
conclusion of the inquest was a narrative conclusion which is attached.
The medical cause of death was:
1a intestinal perforation
1b caecal volvulus
4
CIRCUMSTANCES OF THE DEATH
Mrs Dullabh initially presented to the Accident and Emergency Department at
the Homerton University Hospital on 9 October 2017. X-rays established that
she had gas filled loops of small bowel but did not show radiographic features of
bowel obstruction or perforation. Plans were made for further investigations to
be undertaken as an outpatient and she was discharged. She returned to the
hospital the following evening with increasing pain. A CT scan established
sigmoid diverticular disease and a distended stomach. No signs of obstruction
were seen. A decision was made to discharge her from hospital but the ward
manager of the ACU decided that she should remain in hospital until she was
reviewed by the surgical team. A number of requests were made by the ward
for Mrs Dullabh to be reviewed as her levels of pain were increasing. Mrs
Dullabh was not reviewed by a member of the surgical team until 1am on 12
October 2017. The on-call surgical registrar requested an urgent x-ray in order
to rule out bowel perforation. At 5.30 am a radiographer advised that Mrs
Dullabh needed to be reviewed urgently by the on-call surgical registrar as the
x-ray showed clear signs of bowel perforation. The on-call surgical registrar’s
view was that Mrs Dullabh required an urgent laparotomy. When he discussed
the case with the on-call surgical consultant, he was advised to seek further
information from the radiologist. The on-call surgical registrar found that there
were no arrangements in place to obtain a radiologist’s opinion during the early
hours of the morning. Nursing observations made at 6 am showed that Mrs
Dullabh was in a state of hypovolaemic shock. Mrs Dullabh was handed over to
the daytime on-call surgical team at 8 am. She continued to deteriorate and the
daytime on-call surgeon’s view was that surgery was very high risk and Mrs
Dullabh was unlikely to survive. Attempts were made to resuscitate her in order
that surgery could be performed. Mrs Dullabh did not respond to these
measures and died on the afternoon of 12 October 2017. Since Mrs Dullabh’s
death, the hospital has taken steps to increase the level of out of hours surgical
cover.
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) Whilst the Hospital has arrangements in place to obtain out of hours
reports from radiologists in relation to CT and MRI scans, there is no
similar arrangement for x-rays.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and 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 6 February 2019. 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:
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.
Sarah Bourke
Assistant Coroner
11 December 2018
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