Source · Prevention of Future Deaths

Thomas Jordan

Ref: 2016-0287 Date: 10 Aug 2016 Coroner: David Hinchliff Area: Yorkshire West (East) Responses identified: 1 / 2 View PDF

Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.

Date 10 Aug 2016

56-day deadline 5 Oct 2016 est.

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ (1) Healthcare staff at the Prison continued to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued: (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.

(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him; but this was not immediately available to Healthcare staff and was not reviewed by them.

(4) This was an obvious drug error; but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death (5) require that the Head of Healthcare at Her Majesty's Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison's Healthcare facility electronically to ensure that any directions advice as to future care are received promptly and can take immediate effect.

(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose_

Responses

1 respondent

Care UK Private Sector

28 Sep 2016 PDF

Action Planned

Leeds Teaching Hospital has agreed to issue an electronic summary with all patients who transfer back to HMP Leeds following discharge. IT personnel from both the Hospital and Care UK will create a pathway to ensure all summaries are appropriately shared, and written summaries are provided in sealed envelopes in the meantime. (AI summary)

View full response

Dear Mr Hinchliff, Inquest touching the death of Thomas George Jordan - Regulation 28 Report I write in response to your Regulation 28 Report dated 10 August 2016. I have also had sight of the letter from Rachel Howitt, Incident and Assurance Manager, Leeds Community Healthcare dated 4 August and your letter of 10 August in response. Further to that correspondence, the Head of Healthcare at HMP Leeds has discussed the above with the Clinical Director for Urgent Care at Leeds Teaching Hospital. The Director has agreed that an electronic summary can be issued with all patients who transfer back to HMP Leeds following discharge from a hospital admission. The Hospital currently send an electronic summary to the registered GP and the process for sending the same to the prison can be incorporated within their system. IT personnel from both the Hospital and Care UK will create a pathway that ensures all summaries are appropriately shared. In the meantime, the Director will ensure that written summaries are provided in a sealed envelope for all hospital discharges and these will accompany the patient back to the prison. I trust that this addresses your concern but please do not hesitate to contact me if I can be of any further assistance.

Report sections

Investigation and inquest

On 7th August 2015 commenced an Investigation into the death of Thomas George Jordan; aged 80 years. The Investigation concluded at the end of the Inquest on 28th June 2016. The Conclusion of the Inquest was: "Thomas George Jordan was a remand Prisoner at Her Majesty's Prison; Leeds who suffered with a number of chronic medical conditions as befits his age_ He became unwell and was admitted to St James's University Hospital, Leeds where his death was confirmed at 1955 hours on 6th August 2015" The cause of death being:- Ischaemic Heart Disease (b) Coronary Artery Atheroma Diabetes Mellitus_ Conclusion Natural Causes

Circumstances of the death

Thomas George Jordan was remanded in custody at Her Majesty's Prison, Leeds in April 2015 after breaching his bail conditions_ On the morning of 6th August 2015 his heart rate was fast and irregular. He was therefore admitted to Leeds General Infirmary with central chest pain; breathlessness, fast atrial fibrillation and low blood pressure_ He described having felt unwell for the previous three weeks: Clinically he was dehydrated and showed signs of kidney impairment and severe metabolic acidosis. He was reviewed by a Cardiologist and an ultrasound scan of his heart was performed. Later he was transferred to St James's University Hospital, Leeds, where his condition deteriorated . He went into cardiac arrest and despite cardiopulmonary resuscitation his death was confirmed at 1955 hours on 6" August 2015. 1(a)

Action should be taken

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

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0287
Date of report: 10 August 2016
Coroner: David Hinchliff
Coroner area: Yorkshire West (East)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Oct 2016 (estimated).

Sent to

Head of Healthcare, HMP Leeds

Medical Director, Leeds Teaching Hospitals, NHS Trust

Part of a series

2 reports

None 0 responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.