Source · Prevention of Future Deaths
Michelle Roach
Ref: 2018-0302
Date: 28 Nov 2018
Coroner: Heidi Connor
Area: Berkshire
Responses identified: 0 / 2
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GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.
Date
28 Nov 2018
56-day deadline
23 Jan 2019 est.
Responses identified
0 of 2
Coroner's concerns
GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.
View full coroner's concerns
In relation to GP Management
(1) I believe should consider reviewing and updating her knowledge in relation to the signs and symptoms of venous thromboembolism.
(2) I believe should review her record-keeping practices.
(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review clinical knowledge in this area
Classification: OFFICIAL-SENSITIVE
Classification: OFFICIAL-SENSITIVE
-3-
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
and her record keeping.
Hospital Management
(1) I consider that the trust should review its level of cover by medical registrars at night. Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust.
(1) I believe should consider reviewing and updating her knowledge in relation to the signs and symptoms of venous thromboembolism.
(2) I believe should review her record-keeping practices.
(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review clinical knowledge in this area
Classification: OFFICIAL-SENSITIVE
Classification: OFFICIAL-SENSITIVE
-3-
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
and her record keeping.
Hospital Management
(1) I consider that the trust should review its level of cover by medical registrars at night. Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust.
Report sections
Investigation and inquest
I conducted an Inquest into the death of Michelle Roach that was heard at Reading Town Hall between 6th and 9th November 2018. I recorded a narrative conclusion as follows:
Natural causes contributed to by neglect in her clinical management from 0911 hrs on 29th January 2014 until 1807 hrs on 30th January 2014.
Natural causes contributed to by neglect in her clinical management from 0911 hrs on 29th January 2014 until 1807 hrs on 30th January 2014.
Circumstances of the death
The family asked us to refer to the deceased as Michelle at the inquest. I have reflected that request in this report.
I have attached my detailed summing up and conclusions provided at the conclusion of this inquest which sets out the history in detail.
Classification: OFFICIAL-SENSITIVE
Classification: OFFICIAL-SENSITIVE
-2-
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Brief Summary
Michelle Roach was a 32 year old woman who had given birth to her first child on the 17th December 2013. She had a past medical history which included treatment for asthma and hypertension.
She attended her GP on the 15th January 2014 after suffering a fainting episode 3 days earlier. Her hypertension medication was adjusted and she was seen again two weeks later – on 29th January 2014.
At this appointment, she reported a further collapse. Her heart rate was very high. The question of whether Michelle was short of breath at this appointment was a matter of factual dispute between the witnesses. I made a finding of fact that Michelle was likely to have been short of breath or at the very least to have reported being short of breath earlier that day.
During a telephone appointment on 30th January 2014, Michelle’s husband reported that she was too weak to attend an appointment. The GP’s advice was for Michelle to attend 4 days later. A further telephone call was made to the GP later that day, which resulted in a home visit and subsequent admission to hospital
– on the evening on the 30th January 2014.
Despite being admitted as a “?PE” patient, there was inadequate senior review at the hospital resulting in a delay in the administration of anticoagulants. Michelle died in the early hours of 31st January 2014.
I have attached my detailed summing up and conclusions provided at the conclusion of this inquest which sets out the history in detail.
Classification: OFFICIAL-SENSITIVE
Classification: OFFICIAL-SENSITIVE
-2-
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Brief Summary
Michelle Roach was a 32 year old woman who had given birth to her first child on the 17th December 2013. She had a past medical history which included treatment for asthma and hypertension.
She attended her GP on the 15th January 2014 after suffering a fainting episode 3 days earlier. Her hypertension medication was adjusted and she was seen again two weeks later – on 29th January 2014.
At this appointment, she reported a further collapse. Her heart rate was very high. The question of whether Michelle was short of breath at this appointment was a matter of factual dispute between the witnesses. I made a finding of fact that Michelle was likely to have been short of breath or at the very least to have reported being short of breath earlier that day.
During a telephone appointment on 30th January 2014, Michelle’s husband reported that she was too weak to attend an appointment. The GP’s advice was for Michelle to attend 4 days later. A further telephone call was made to the GP later that day, which resulted in a home visit and subsequent admission to hospital
– on the evening on the 30th January 2014.
Despite being admitted as a “?PE” patient, there was inadequate senior review at the hospital resulting in a delay in the administration of anticoagulants. Michelle died in the early hours of 31st January 2014.
Inquest conclusion
Natural causes contributed to by neglect in her clinical management from 0911 hrs on 29th January 2014 until 1807 hrs on 30th January 2014.
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Report details
- Reference
- 2018-0302
- Date of report
- 28 November 2018
- Coroner
- Heidi Connor
- Coroner area
- Berkshire
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Jan 2019 (estimated).
Sent to
- Royal Berkshire Hospital
- Waterfield Practice