Source · Prevention of Future Deaths

Terence Stilges

Ref: 2016-0293 Date: 30 Jun 2016 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 1 / 2 View PDF

Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.

Date 30 Jun 2016

56-day deadline 25 Aug 2016

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

(1) A discharge summary was prepared several days in advance for this patient: This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the

Responses

1 respondent

NHS England NHS / Health Body

23 Aug 2016 PDF

Action Taken

NHS England supports the Heart of England NHS Foundation Trust's actions to review electronic systems, ensure junior doctors are aware of the discharge process through training, have individual clinicians review the event in their annual appraisal, and include the event in their internal quality improvement process. (AI summary)

View full response

Dear Mrs Hunt; Inquest into the death of Mr Terence Stilges Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 30 June. note the significant concerns raised by you in the relation to the discharge arrangements provided to Mr and | would Iike to express my sincere condolences and apologies to the family at this difficult time. thank the Heart of England NHS Foundation Trust for carefully considering the issues raised by you: Although the Trust had electronic systems in place to prevent this event from occurring; they have acknowledged that these were not followed and have taken appropriate to prevent a re-occurrence: are in the process of reviewing the electronic systems to ensure robustness; they have a comprehensive programme in place t ensure that junior doctors are aware of the discharge process; the individual clinicians involved have been asked to review this significant event in their annual appraisal; and the event will form part of their internal quality improvement process the "Risky Business Forum" to ensure that all learning is understood by clinicians High quality care for all; now and for future generations Stilges fully steps they training

believe that this response and the actions articulated within it are appropriate, deliverable and proportionate and am therefore able to support the content of the response from Heart of England NHS Foundation Trust. am grateful to you for bringing these matters to NHS England's attention,

Report sections

Investigation and inquest

On 09/03/2016 commenced an investigation into the death of Terence Henry Stilges The investigation concluded at the end of the inquest 28th June 2016. The conclusion of the inquest was that the deceased died from a myocardial infarction which was not diagnosed before he was discharged home from hospital on 09/12/15_ troponin blood test and referral to a cardiologist should have been completed which would have resulted in him staying in hospital for further treatment;

Circumstances of the death

The deceased was admitted to Birmingham Heartlands Hospital on 06/12/15 having collapsed. He suffered from severe COPD. The cause ofhis collapse was investigated with a provisional diagnosis of pulmonary embolism. Tests were undertaken including a troponin test (a blood test which is a marker of myocardial infarction and acute pulmonary embolism) He was reviewed on the ward round on 08/12/15 when the troponin result was 520. A further troponin was taken at 10.00 on 08/12/15. This sample was not tested as it was incorrectly labelled so another sample was taken at 16.00.He was reviewed on the morning ward round on 09/12/15 when he said he wanted to go home to attend his sister'$ funeral The troponin had again been incorrectly labelled so the result was unavailable: The medical records clearly documented that the plan was for the deceased to go home: The nursing notes recorded his discharge at 11.05. At 17.21 on 10/12/15 the deceased was readmitted to Birmingham Heartlands Hospital with severe shortness of breath and intermittent chest pain: He was diagnosed as suffering from an acute myocardial infarction. He did not satisfy the criteria for urgent intervention. He was treated in hospital until he died following a cardiac arrest on 12/12/15.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you, Heart of England NHS Foundation Trust; have the power to take such action,

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0293
Date of report: 30 June 2016
Coroner: Louise Hunt
Coroner area: Birmingham and Solihull

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: 25 Aug 2016.

Sent to

Heart of England NHS Foundation Trust

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.