Source · Prevention of Future Deaths

Thomas Burchell

Ref: 2016-0002 Date: 4 Jan 2016 Coroner: Andrew Cox Area: Plymouth Torbay and South Devon Responses identified: 1 / 2 View PDF

Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.

Date 4 Jan 2016

56-day deadline 29 Feb 2016

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.

View full coroner's concerns

_ (1) Inadequate and incomplete record keeping: This is in respect of both medical and nursing records In particular, the seizure chart started late and finished early. It is far from an accurate or complete record of what happened to Thomas (2) In a neurosurgical unit understand there will be patients having seizures on a regular basis further understand that it is extremely rare for those seizures to progress as befell Thomas and then prove resistant to treatment: Where a patient does develop seizures, however, consider that there should be a far more robust and complete record of the relevant events

Responses

1 respondent

The Borchardt Medical centre Other

29 Jan 2016 PDF

Action Taken

The practice changed its policy so staff must add a code to computerised records the same day they arrive, alerting clinicians. A clinical meeting reviewed NICE and local guidelines for suspected brain tumours; clinicians added reflections to appraisal documents. (AI summary)

View full response

Dear Sir /Madam Response to the Coroner' $ concerns with regard to the death of Thomas Alexander Burchell and his subsequent inquest My name is Dr Nicholas Stephen Smith: am now Senior Partner at the Borchardt Medical Centre. assumed that role on 1 September 2015 and in 2011 was a Partner at the Practice. In response to the Coroner's matters of concern:- The first matter of concern is aboutl thoughts and actions left the Practice in July 2014 and left the General Medical Council Medical Register shortly afterwards The Practice currently has no formal contact with him so | do not feel myself in a position to comment on his thought processes or actions: With regard to the second concern, we have now changed Practice policy and have insisted that the staff will add a code to the computerised records the same day that records arrive in the Practice so clinicians will be aware that records are in the building and can ask Reception staff to access them for the clinician so are available for consultation. With regard to the third concern, took the opportunity to call a clinical meeting on 22 January: We have clinical meetings towards the end of every month and | used this meeting to review current guidance for suspected brain tumours: they

Contd/_ AIl partners, salaried doctors and training grades that were in surgery that day attended and we reviewed:- 1 NICE referral guidelines for suspected cancer 2005
2. NICE suspected cancer recognition and referral guidelines update 2015
3. NICE assessment and management of headaches in over-12s September 2012 4 General Practice notebook online medical reference "brain tumours" (urgent referral guidance for suspected cancers) as well as 5 The local guidance for "north-west headache management guidelines for adults based on NICE GC1SO which were distributed to Practices on 5 November 2015 and approved by the Greater Manchester Medicines Management Group in June 2015" _ A hard copy of the presentation is available; if required: After the clinical meeting, clinicians reflected on the information given and have added those reflections to their appraisal documents for 2016 which will contribute to their next revalidation. hope have able to answer the Coroner's matters of concern on behalf of the Practice. realise nothing can say can ease the of Mr Burchell's family and remain ready to assist the Coroner with any future correspondence:

Report sections

Investigation and inquest

On 18/07/2011 commenced an investigation into the death of Thomas Alexander Burchell; age
22. The investigation concluded at the end of the inquest on 18 December 2015. The conclusion of the inquest was that Thomas died from Natural Causes. The medical cause of death at post mortem was given as: (a) Brain Swelling and Infarction; (b) Glioblastoma (WHO Grade 4)

Circumstances of the death

Mr Burchell's tumour was identified by CT Scan performed at the Royal Devon & Exeter Hospital on July 2011_ There was then a discussion with the Neurosurgical Team at Derriford Hospital and the management plan for that weekend was as follows; prescribe and administer Dexamethasone; perform an MRI to exclude a primary tumour elsewhere and discuss at the MDT on the Thursday for a definitive management plan. In the event; Thomas underwent an MRI scan at R D & E on 4 July as a consequence of which it was agreed to transfer Thomas trom R D & E to Derriford that evening with a view to him undergoing a craniotomy on list the following In the early hours of 5 July, however; Thomas began to develop seizures (see entry on page 150 timed 06.15). There was a discussion with the neurosurgical SPR and loading dose of Phenytoin with an urgent CT was advised: The progression of the seizures from that in time onwards is unclear. In her evidencel said that when she went into the operating theatre at 0900 hours she understood Thomas still to be having focal motor seizures_ The entries between 06.15 and 08.50 are scant: The entry on page 152 of the notes is written retrospectively and does not indicate the time to which the entry relates. The entry at 08.50 on page 153 simply identifies that Thomas is having "seizures" It does not specify whether these are focal motor, generalised, tonic clonic or other_ Similarly the entry at 09.15 does not specify the nature of the seizures that Thomas was having at that time The_seizure_chart_reflects_the_fact_that_at_09.15_Thomas'seizures_had_become_generalised 3 The Crescent, Plymouth, PLI 3AB Tel 01752 204 636 Fax 01752 313297 day: point

These continued to be recorded until 09.56. The seizure chart was started three hours after seizures began and stopped nearly three hours before Thomas' transfer to the ICU. There is nothing in the notes to reflect what was happening from 09.56 to 11.30 when came out of the operating theatre and Thomas was already in tonic clonic seizures.

Action should be taken

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

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Shared signals

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Report details

Reference: 2016-0002
Date of report: 4 January 2016
Coroner: Andrew Cox
Coroner area: Plymouth Torbay and South Devon

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: 29 Feb 2016.

Sent to

Hospital NHS Trust Derriford Hospital

Borchardt Medical Centre

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.