Western Sussex Hospital Trust shared the PFD report with relevant staff, conducted an RCA, and confirmed a Trust Surgical Board ratified Transfer Policy is in place for complex trauma patients needing specialist surgery at the Major Trauma Centre. They also included the application of spanning external fixator, elevation, and early mobilisation within the protocol. (AI summary)
Source · Prevention of Future Deaths
Linda Phillipson
Ref: 2020-0172
Date: 8 Sep 2020
Coroner: Veronica Hamilton-Deeley
Area: Brighton and Hove
Responses identified: 1 / 1
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Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.
Date
8 Sep 2020
56-day deadline
5 Jan 2021 est.
Responses identified
1 of 1
Coroner's concerns
Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.
View full coroner's concerns
(1) The delay in applying the external fixator (2) The apparent failure to mobilize the patient
Responses
Western Sussex Hospital Trust
NHS / Health Body
Action Taken
Dear Mrs Veronica Hamilton-Deeley Re: Regulation 28 Report Mrs Linda Phillipson Thank you for your letter dated 8th September 2019 which included a formal copy of the Regulation 28 report to Prevent Future Deaths The Trust welcomes the opportunity to review the way that patients who sustain trauma are managed: As part of this process, the PFD report has been shared with the Trauma and Orthopaedic Consultants, Radiologists, Physiotherapists, ward nurses and through teaching with the junior doctors on both sites of the Trust: It has also been discussed at the Trust Trauma and Orthopaedic Clinical Governance meeting and a further thorough RCA been conducted which will be shared with Mrs Linda Phillipson's family and Sussex Trauma Network Consultants We can confirm that a Trust Surgical Board ratified Transfer Policy has been in place between Brighton & Sussex University Hospitals and Western Sussex Hospitals NHS Foundation Trust hospitals for the management of complex trauma patients who need specialist surgery at the Major Trauma Centre- The immediate management of major trauma in Western Sussex Hospitals whilst awaiting transfer is included within the transfer protocol: The application of spanning external fixator for all Peri-articular complex fractures, elevation and early mobilisation with physiotherapists been also included within the protocol to prevent any further similar occurrence Further to this, there are also plans for regular Educational and Clinical Governance meetings between Brighton & Sussex University Hospitals, Eastern Sussex Hospitals NHS Trust ad Western Sussex Hospitals for complex trauma management beginning from January 2021 Mrs Phillipson'$ CT scan findings were also discussed at Radiology Events and Learning meetings (REALM, formerly discrepancy meeting) to all radiologists in the department and the learning from this shared. The Trust was saddened by Mrs Linda Phillipson's death and would like to give our reassurance that the Trust has taken the opportunity to review our current practice to ensure we manage patients who have sustained major trauma in the most safe and effective way:
Report sections
Investigation and inquest
On 1ih December 2019 I commenced an investigation into the death of Linda Ann PHILLIPSON The investigation concluded at the end of the inquest on 2nd September 2020.The conclusion of the inquest was MEDICAL MISADVENTURE BEING MAJOR PULMONARY EMBOLISM DURING SURGERY FOR A COMPLICATED TIBIAL FRACTURE ON A BACKGROUND OF UNNECESSARY DELAYED EXTERNAL FIXATOR AND SUBOPTIMAL CARE BOTH LEADING TO INCREASED IMMOBILITY BEFORE TRANSFER TO THE SOUTH EAST TRAUMA CENTRE
Circumstances of the death
See Record of Inquest
Copies sent to
1.Mr2. Brig~ niversity Hospital Trust3. Secretary of State for Health, Department of Health4. Simon Stevens, Chief Executive, NHS England :1. Dr CCG2. Mr. , Head of Quality and Nursing CCG3. MrChief Executive CQC
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Report details
- Reference
- 2020-0172
- Date of report
- 8 September 2020
- Coroner
- Veronica Hamilton-Deeley
- Coroner area
- Brighton and Hove
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: 5 Jan 2021 (estimated).
Sent to
- Western Sussex Hospital Trust