Source · Prevention of Future Deaths

Robert Power

Ref: 2018-0221 Date: 9 Jul 2018 Coroner: Katy Skerrett Area: Gloucestershire 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified a risk that patients treated as outpatients could be lost to follow-up care, noting that one patient was not followed up for eight years without explanation.

Date 9 Jul 2018

56-day deadline 18 Nov 2018 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

The coroner identified a risk that patients treated as outpatients could be lost to follow-up care, noting that one patient was not followed up for eight years without explanation.

View full coroner's concerns

Robert whilst treated as a patient by the trust was essentially lost to follow up between 2007 2015 No explanation was given as to why this happened For the reasons given in my summary of evidence | determined that there was no evidence that this area of concern had any direct causative impact on Robert's death_ However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are not lost to follow Up care It is acknowledged that significant steps have already been made

Responses

1 respondent

North Bristol NHS Trust

NHS / Health Body

Indexed date: 9 Aug 2018 PDF

AI-classified response stance Noted

AI-generated response summary

• The Trust confirmed it operates under different systems compared to 2008. • The Trust stated that processes have been introduced to arrange follow-up appointments. • The Trust stated that processes have been introduced to monitor and manage patients on an allocated pathway.

View full response

NHS] North Bristol NHS Trust Trust Headquarters Southmead Hospital Bristol Southmead Road Westbury-on-Trym Bristol 09 August 2018 BS1O SNB Tel: 0117 41 43816 Website: http IWWnbtnhs_Uk FAO: HM Senior Coroner, Ms Katy Skerrett Gloucestershire Coroner's Court Corinium Avenue Barnwood Gloucester GL4 3DJ Re: Regulation 28 Report to Prevent Further Deaths The late Mr Robert Andrew Power. am writing in response to your letter dated 10th July 2018. Thank you for acknowledging receipt of information already provided by the Trust dated 18th
2018. The information provided confirms the Trust is now working under different systems than in 2008 and that processes have been introduced to arrange follow-up appointments and monitor and manage a patient on an allocated pathway. Following review of the information provided, can confirm that the Trust does not have any additional submissions that would assist the Coroner further in this case_

Report sections

Investigation and inquest

On the 22nd May 2017 | commenced an investigation into the death of Robert Andrew Power The investigation concluded at the end of the inquest on the 4ih May 2018. The conclusion of the inquest was natural causes_ The medical cause of death was 1A Bronchopneumonia and urinary tract infection, 1B Multiple Sclerosis_

Circumstances of the death

Robert Andrew Power 'Robert" was a 49 year old man who lived in a care home specialising in neurological conditions He had history of significant and alcohol abuse In 2007 he suffered a marked change in his physical abilities and he underwent extensive investigations_ He was diagnosed with gliomatosis cerebri, and discharged to terminal care home_ This diagnosis was incorrect. In 2014 his GP requested further assessment of Robert Neurological opinion was sought; and it was determined that Robert had suffered significant damage to his brain, and had a chronic undefined inflammatory condition affecting his brain In July 2015 Robert was admitted to a care home specialising in neurological management Thereafter whilst Robert's condition remained relatively stable, he was admitted to hospital on multiple occasions suffering with aspiration pneumonia, and or seizure activity. Following ongoing deterioration_ and after discussion with his family, it was agreed there would be no further escalation of treatment in the event of further deterioration On the 12th April 2017 Robert was admitted to hospital suffering with aspiration pneumonia: He was discharged on the 4"h 2017 for palliative care His condition steadily deteriorated. He was regularly reviewed by his GP. Robert passed away on the 17th 2017 . During the course of the inquest the evidence revealed a matter giving rise t0 concern_ The MATTER OF CONCERN was as follows Robert whilst treated as a patient by the trust was essentially lost to follow up between 2007 2015 No explanation was given as to why this happened For the reasons given in my summary of evidence | determined that there was no evidence that this area of concern had any direct causative impact on Robert's death_ However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are not lost to follow Up care It is acknowledged that significant steps have already been made

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

Similar PFD reports

Shared signals

Report details

Reference: 2018-0221
Date of report: 9 July 2018
Coroner: Katy Skerrett
Coroner area: Gloucestershire

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: 18 Nov 2018 (estimated from the Judiciary.uk publication date).

Sent to

North Bristol NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.