Source · Prevention of Future Deaths

John Berrow

Ref: 2021-0080 Date: 7 Jan 2021 Coroner: Caroline Saunders Area: Gwent Responses identified: 1 / 1 View PDF

An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.

Date 7 Jan 2021

56-day deadline 25 May 2021 est.

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.

View full coroner's concerns

Igave oral evidence at the inquest hearing: In evidence he admitted that he failed to consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm and has rectified this in his current practice: He also stated that there were no practical reference tools or clinical manuals available to him within Specsavers and was dependent upon referring to Google to assist him in his clinical decision making: was also informed that whils Ishared his experience locally, that there is no mechanism for disseminating information relating to clinical incidents or to improve learning from similar events amongst practitioners at Specsavers:

Responses

1 respondent

Specsavers Other

PDF

Action Planned

Specsavers will commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar available to all professional staff within the Company. They also hope to make the training available for the wider optical community. (AI summary)

View full response

Dear Ms Saunders Regulation 28 report John Berrow (deceased) Your letter of January 2021 enclosing your Regulation 28 report has been forward to me as the Professional Services Consultant for Specsavers I write on behalf of the Specsavers Optical Group to respond to the matters raised in your report: Firstly, would like to offer my condolences to Mr Berrow's family for their loss So far as reference tools and clinical manuals are concerned, we do not provide paper textbooks and manuals within the stores as these will become out-of-date however; computers are provided and staff are able to access clinical evidence, guidance; journals and optometry textbooks via the College of Optometrists website: This has the benefit of being up-to-date. Staff also have access to peers more senior colleagues within the store or through the professional services team, which can give advice. My understanding is that the optometrist accessed the publically available local referral guidelines online to ensure that he followed the current; up-to-date referral guidelines Each area will have its own guidelines This was an unusual presentation We appreciate the importance of sharing experience and learning across the Company: We are liaising with Specsavers Professional Training team to commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar or other similar mechanism which will be available to all Professional staff within the Company: We also hope to make the training available for the wider optical community outside the Company so that there is an opportunity for non-Specsavers practitioners to learn any and all matters arising out of Mr Berrow's sad death: If I can provide any further information, please do not hesitate to contact me:

Report sections

Investigation and inquest

On 18/10/19 an investigation was opened into the death of John BERROW The investigation concluded at the end of the inquest on: 1/12/20 The conclusion of the inquest was recorded as: Natural Causes The medical cause of death was: 1a) Subarachnoid haemorrhage 1b Ruptured cerebral aneurysm

Circumstances of the death

On 11t October 2019 John Berrow attended the Specsavers Opticians in Newport because he was suffering unequally sized pupils. John stated that his eyesight was altered and he complained of increased pressure or heaviness. An examination was performed by the optometrist who noted the disparity in size. Mr Campbell considered whether John's symptoms could be as a result ofan aneurysm or increased intracranial pressure, but the tests he performed reassured him that John's neurological function was intact. berry from diagnosed a condition known as Adie's pupil an unusual neurological disorder in which the ability of the pupil to constrict is impaired, usually in one eye. This is not an emergency and as a result John was referred on a routine basis to the eye hospital_ John left the opticians at about 13:OOhrs John then went to the Queen's Hotel in Newport and collapsed at about 15.2Spm, he was resuscitated and taken to hospital. On arrival at hospital all attempts were made to fully resuscitate John but sadly his condition was irretrievable and John died at 16.50 The cause of John's death was confirmed as a ruptured Aneurysm: The neurological symptoms including unequal pupil size that John exhibited at his assessment at Specsavers should have resulted in John being advised to attend hospital for assessment: Given the severity and nature of his collapse however, there is no evidence that John'$ death would been avoided.

Action should be taken

hours: Berry have action should be taken to prevent future deaths and believe vou have In my opinion the power to take such action. Lshouldbe gratefulif the following _information_be provided tome: resources available for clinical staff working at Specsavers to access up to Confirm the date clinical information relating to potentially life threatening conditions: information relating to Mr Berrow's death and his presentation is to be Confirm how minimize the risks of missing symptoms allied to Berry Aneurysms in disseminated to the future:

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Report details

Reference: 2021-0080
Date of report: 7 January 2021
Coroner: Caroline Saunders
Coroner area: Gwent

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 May 2021 (estimated).

Sent to

Specsavers UK

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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