Source · Prevention of Future Deaths

Christopher MacMorland

Ref: 2016-0415 Date: 16 Nov 2016 Coroner: David Horsley Area: Portsmouth and South East Hampshire Responses identified: 1 / 1 View PDF

Despite being under the care of gastroenterologists, the patient was not treated in a specialist gastroenterology ward despite multiple requests, and consultant requests for patient transfer to specialist wards are commonly not implemented.

Date 16 Nov 2016

56-day deadline 11 Jan 2017

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

was told in evidence at the Inquest that despite Mr MacMorland being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward even though the consultants had during that time requested such a transfer on five separate occasions. Given the nature of his medical problems, from the evidence heard, am of the opinion that he could have benefitted from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome_ was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented.

Responses

1 respondent

Portsmouth Hospitals NHS Trust NHS / Health Body

20 Dec 2016 PDF

Action Taken

The Trust implemented a 'buddy' ward system where patients of certain specialties are cohorted only into the appropriate specialist ward or specific buddy ward. (AI summary)

View full response

Dear Mr Horsley Regulation 28 letter Re: Christopher MacMorland DOB 13.10.51 Inquest date: November 2016 The Regulation 28 letter refers to the care of this patient which was provided by both an Upper Gastrointestinal (UGI) Surgeon and a Gastroenterologist: Your concerns related to the failure to transfer the patient to a Gastroenterology ward as requested by the Gastroenterologist The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon: The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised. By way of further assurance, since this death in 2015, the Hospital has begun 'buddy' ward system whereby patients of certain specialty are cohorted only into the appropriate specialist ward Or specific buddy ward This means that consultants will have their patients only on one other ward if their own base ward is full, trust this provides you with appropriate reassurance_

Report sections

Investigation and inquest

On 22nd July 2016 | commenced an investigation into the death of Christopher Allen MacMORLAND (D.O.B. 13/10/1951). The investigation concluded at the end of the inquest on November 2016. The conclusion of the inquest was: Medical cause of death: la: Multiple Organ Failure Ib: Sepsis Ic: Spontaneous Bacterial Peritonitis and Pelvic Abscess Il: Myocarditis, Cardiac Hypertrophy, Chronic Obstructive Pulmonary Disease and Oesophagectomy for Carcinoma of the Oesophagus 2012_ Coroner's Conclusion as to the death: Death due to Natural Causes_

Circumstances of the death

Mr MacMorland was admitted to Queen Alexandra Hospital between 14th and 20th October 2015 having had difficulty feeding: feeding tube was inserted and he returned home_ He was readmitted to the hospital on 10th November 2015 with abdominal pain and distension, feeling generally unwell. Despite treatment, his condition deteriorated and he died at the hospital on 5" December 2015.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.

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Report details

Reference: 2016-0415
Date of report: 16 November 2016
Coroner: David Horsley
Coroner area: Portsmouth and South East Hampshire

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: 11 Jan 2017.

Sent to

Portsmouth Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.