Source · Prevention of Future Deaths

Patrick Curran

Ref: 2016-0258 Date: 14 Jul 2016 Coroner: Andrew Bridgman Area: Manchester (South) Responses identified: 1 / 1 View PDF

Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.

Date 14 Jul 2016

56-day deadline 8 Sep 2016 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.

View full coroner's concerns

It is highly likely that Mr Curran had pneumonia on 12th February, hence his presentation as described by the Specialist Sister: It is possible that the pneumonia was present at the chest drain reviews. It causes me great concern that a patient who must have been presenting as unwell and not as expected at a 4 weeks post-operative was not only not seen by a doctor; but was discharged without the Consultant in charge's knowledge_ also have concerns about the fact that over 3 appointments at & 'nurse-led' clinic despite there being issues with the chest drain Mr Curran was not once reviewed by doctor: told me that he spoke with the Specialist Sister involved but am not salisied that this provides me with adequate assurance that; a) first post-operative_reviews_and discharges Of patients without a doctor seeing very that patient is not a common and accepted practice, in main because in many of the answers given to me on this element of the care provided to Mr Curran was keen to enlighten me as to how experienced this particular Specialist Sister was_ b) and in the circumstances this will not happen again. had no evidence as to whether or not had Iseen Mr Curran the outcome would have been different It seems to me that inere was at least the possibility that the outcome would have been different: In my opinion there is a risk that future deaths will occur unless action is taken. That Wythenshawe Hospital have adopted or condoned a practice whereby first post-operative reviews are conducted by nursing staff (of whatever specialist level of training) without any or any adequate medical overview:
2. That Wythenshawe Hospital have adopted or condoned practice whereby patients can be, and are, discharged from care at first post-operative review, or indeed any review, by nursing staff (of whatever specialist level of training) without any or any adequate medical overview_

Responses

1 respondent

Manchester University NHS Foundation Trust NHS / Health Body

5 Sep 2016 PDF

Action Taken

The hospital strengthened post-operative clinics by ensuring a consultant is present in the same clinic, along with nurses, and radiology reports X-rays with any concerns. (AI summary)

View full response

Dear Mr Bridgman, Re: PFD Patients Name: Patrick Curran D.O.B: 06.12.1933 DO.D: 22.02.2016 RM No: RM267048 am responding to the Regulation 28 Prevention of Future Deaths Report Issued to University Hospitals of South Manchester (UHSM) on 14 July 2016. Concern: That Wythenshawe Hospital have adopted or condoned a practice whereby first post-operative reviews are conducted by nursing staff whatever specialist level of training) without any or any adequate medical overview: Thank you for making the Trust aware of your concerns In line with a national move towards nurse-led clinics the expertise and training of our nursing staff renders them very capable of conducting post-operative clinics in the cardiothoracic unit: Thoracic surgery petiente are seen in the outpatient clinic for their follow' ups by any member of the team and this could be the Consultant; Registrar, SHO or a specialist nurse who has many years of thoracic surgery experience AIl clinics are supported by Consultant cover as required. If there are concerns with a patient are always discussed with the Consultant or if there are any concerns with an X-ray, Radiology are asked to report these Notwithstanding this, we would like t0 reassure you that there was medical oversight at these clinics. When Mr Curran was seen at clinic in February 2016, the clinic would be nurse-led with the consultant surgeon available by telephone_ have strengthened this and now our post-operative clinics are led by nurses but with a consultant present in the same clinic. 2 Concern: That Wythenshawe Hospital have adopted or condoned a practice whereby patients can be; and are, discharged from care at first post-operative review; Or 1 INVESTORS 4 UHSM IN PEOPLE Chairman Barry Clare (of they We LbouT , 8

indeed any review, by nursing staff (of whatever specialist level of training) without any or any adequate medical overview: Thank you for making the Trust aware of your concerns As set out above, the system has been strengthened and a consultant is present at the first post-operative review clinic Mr Curran's X-ray taken on 12 February 2016 did not reveal a chest infection or pneumonia. A plan was made, on the basis that Mr Curran's histology was not currently available, for him to receive his histology at a separate time by way of follow up from The decision regarding chemotherapy was not made until the histology was available: It was therefore, in our view, entirely appropriate, based on his presentation on 12 February 2016 to discharge him albeit without his histology results which were to be given at a later appointment did not feel the need to review Mr Curran but had he been asked to review Mr Curran; it is his view that based on his x-ray and the description of Mr Curran's presentation he would not have admitted him: The X-ray from the 12 February 2016 was compatible with post-operative findings If you require any further information, please do not hesitate to contact me_

Report sections

Investigation and inquest

On 26th February 2016 an investigation was commenced into the death of Patrick Curran who died at Trafford General Hospital on 22nd February 2016. The investigation concluded with an Inquest held on 13th July 2016_ :Medical cause of death Ia Pneumonia Ib Asbestosis, Chronic Obstructive Pulmonary Disease, and Adenocarcinoma of the lung (treated surgically) Ic Smoking and asbestos exposure Coronary artery atheroma Conclusion: Industrial Disease CIRCUMSTANCES @F THE DEATK In December 2015 Mr Curran was diagnosed with Stage 1B lung cancer (T2a NO MO) as determined by PET scan carried out at the Manchester Royal Infirmary: Mr Curran was referred tc Consultant in Thoracic Surgery. On 5"h January 2016 Mr Curran underwent resection of the upper right lobe, and mediastinal Iymph nodes: Following surgery and histology the tumour was re-staged as Stage 3A (T3 N2 MO) poorly differentiated adenocarcinoma. Mr Curran was discharged on the 4"h post-operative day, 9th January 2016 He was discharged with a chest drain in situ: With regard to the chest drain Mr Curran was reviewed in a 'nurse-led' clinic on 18th January, 25th January and 29th January: At the last appointment the chest drain was removed. At none of these appointments was Mr Curran seen by a doctor Mr Curran attended for_his first post-discharge review on 12t February__Hewas seen by a Senior Specialist Nurse in Thoracic Surgery_ It was noted that Mr Curran, looked a bit frail was struggling to recover post-operatively was low in mood had poor appetite and had lost weight; and that his family were encouraging him to have Fortisips between meals in an attempt to regain weight In his statement refers to the fact it was obvious, at that clinic, that Mr Curran would not be able to tolerate adjuvant chemotherapy: That could only be based on the Sister's assessment accepted that such presentation would not be the norm for a 4-weeks post discharge review. A chest xray was taken stated in evidence that he reviewed this xray: In his evidence he said there were no obvious suggestions of an ongoing chest infection. have not seen the radiologists report of that xray: do not therefore know whether that statement is correct either in so far as it related to obvious signs and in addition whether more subtle changes were present Although was asked to review the xray by the Sister he was not asked to see Mr Curran; accepted in evidence that he ought to have been asked to see Mr Curran, and a fortiori he would have done_ Mr Curran was discharged by the Sister back to advised that it would likely be 3-4 weeks before Mr Curran was seen. was not immediately aware that Mr Curran had been discharged and that he had not seen him post-op. An attempt was made to contact Mr Curran on 22nd February. Mr Curran was admitted to Trafford General Hospital on 17lh February: He was unwell: The impression was of & pneumonia that had "been developing for a period of weeks" It was treated, given the history of recent admission for surgery, as a hospital acquired pneumonia and IV Tazocin administered. Treatment was unfortunately not successful and Mr Curran passed away in the early hours of 22nd February:

Action should be taken

In my opinion action should be taken by WythenshaweHospital to investigate circumstances of Mr Curran's discharge from care on 12th February at his first post-operative review without being seen by his operating surgeon, or any other doctor, when he was clearly not recovering well and in with expectations_ Having carried out such an investigation to then set in place a system that would avoid a recurrence of the same, whether or not the patient presents as unwell:

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Report details

Reference: 2016-0258
Date of report: 14 July 2016
Coroner: Andrew Bridgman
Coroner area: Manchester (South)

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: 8 Sep 2016 (estimated).

Sent to

South Manchester University Hospital NHS Trust

Source links

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Data: judiciary.uk under OGL.