Margaret Pilgrim

Dear Coroner Hayes, REGULATION 28: REPORT TO PREVENT FUTURE DEATHS I write in the matter of the late Mrs Pilgrim in response to your recent Regulation 28 Report to prevent future deaths which was issued on 11 June 2024. Ms Pilgrim was admitted to Princess Alexandra Hospital on 3rd June 2023 at 20:45 following a fall at home which resulted in her sustaining multiple grazes to her knees and elbows. Whilst in the Emergency Department she underwent a CT of her head and an x-ray of their right arm, shoulder and chest x-ray. These x-rays demonstrated a minimally displaced fracture at the distal aspect of the right clavicle which was not noted at the time by the ED team. The patient was deemed fit for discharge from a medical point of view and, following review by the trust REACT (Rapid Emergency Assessment Care Team) was discharged the following day.

Unfortunately, she was readmitted on the 22nd June 2023 with a community acquired pneumonia and, despite ongoing care subsequently passed away on the 29th June 2023.

I note that three areas of concern which you have raised and will respond to in turn. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
- The fracture was not identified prior to the patient being discharged, due to the minimal displacement, which was reviewed by ED clinical team and not radiologist. Had the fracture been identified and orthopaedic advice sought, they would have recommended the patient to mobilise without restriction. No follow up would have been deemed necessary with this fracture.
- Aside from when the patient was initially admitted there was no reference to the patient complaining of pain in her shoulder by either the medical team or the therapists who

subsequently assessed her mobility (see next point). At the point of discharge no request for analgesia was made by the patient or her daughter.
- The patient was advised to stay in the ED overnight in order to be seen by the REACT (Rapid Emergency Assessment Care Team) prior to her discharge so that she could be assessed for a potential package of care. Their assessment was that at the time she did not meet the threshold for this however some additional equipment was provided and ordered for her. (2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
- The discharge summary did not reference the fracture as this was not identified at the time of the patient’s attendance to the ED.
- Had the fracture been identified follow up in fracture clinic would not have been required as conservative management would have been recommended (3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence. I hope this letter helps address the concerns raised in your Regulation 28 notice for prevention of future deaths.

Please do not hesitate to contact me if you require any further details.