Source · Prevention of Future Deaths
Mary Hanson
Ref: 2015-0148
Date: 21 Apr 2015
Coroner: Claire Hammond
Area: Preston and West Lancashire
Responses identified: 0 / 1
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There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information on capacity and best interest assessment forms, and a staff nurse may not have been the appropriate person to complete the proforma.
Date
21 Apr 2015
56-day deadline
16 Jun 2015
Responses identified
0 of 1
Coroner's concerns
There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information on capacity and best interest assessment forms, and a staff nurse may not have been the appropriate person to complete the proforma.
View full coroner's concerns
Mary from Mary point Mary
The MATTERS OF CONCEAN are as follows: (1) Hanson had been seen in combined pituitary clinic by consultant neurosurgeon, and consultant endocrinologist on 2 June 2014. Although evidence was that the risks of surgery would have been clearly explained to both Mary Hanson and her daughter at that consultation, and that _he would have stressed that the risk 0 serious harm and death is small;, evidence was that they had not been advised of a risk of death by any clinician; and that her knowledge as to the risk of death was because of her own research carried out on the internet; (2) There is no record in the medical records of that clinic appointment regarding what risks and benefits were discussed; (3) There are no patient information leailets tor patients considering pituitary surgery to take home and digest, something considered should be provided; (4) The clinic letter sent to Hanson's GP following the clinic does not detail the risks and benefits of surgery; (5) The 'capacity assessment proforma' does not have a box to Iill in the date, nor a box for the clinician's signature, or the signature of others consulted during the capacity assessment process; (6) The 'best interests proforma' does not have a box to fill in the date, nor a box for the clinician's signature, Or the signature of other consulted during the capacity assessment process; The best interests proforma' contains five boxes on the final page: "consideration of the person's beliefs and values that would have been likely to influence [their] decision if [they] had capacity; relevant circumstances [they] would take into account were making the decision themselves; the identified risks of the proposed treatment and any alternative treatments; the identified benefits of the proposed treatment and any alternative available treatments; the outcome of the best interest assessment; which should demonstrate the weighing of infomation, reasons for discounting particular point of view or the manner in which weight has been applied to certain views: It should demonstrate your analysis and findings as the named decision maker: These questions are clearly central to the best interests assessment, yet they had not been completed by the Staff Nurse carrying out the assessment and were all lelt entirely blank; (8) Given that GMC guidance on consent is that if a discussion regarding treatment is to be delegated, the person to whom that task is delegated must be suitably trained and qualified, have sufficient knowledge of the proposed treatment and understand the risks involved, it is doubtful whether & staff nurse is likely to be the appropriale person to complete the proforma and take such a decision; (9) When undertook the consent process o the of surgery using Consent Form 4, he did not notice that the boxes on the best interests profora had not been completed; (10)Consent 4 does not contain a section for the clinician to carry out the best interests assessment;, and in particular does not have anywhere to Iist the risks and benetits of treatment;, or the balancing of the two, something which bothb and Ithought it should:
The MATTERS OF CONCEAN are as follows: (1) Hanson had been seen in combined pituitary clinic by consultant neurosurgeon, and consultant endocrinologist on 2 June 2014. Although evidence was that the risks of surgery would have been clearly explained to both Mary Hanson and her daughter at that consultation, and that _he would have stressed that the risk 0 serious harm and death is small;, evidence was that they had not been advised of a risk of death by any clinician; and that her knowledge as to the risk of death was because of her own research carried out on the internet; (2) There is no record in the medical records of that clinic appointment regarding what risks and benefits were discussed; (3) There are no patient information leailets tor patients considering pituitary surgery to take home and digest, something considered should be provided; (4) The clinic letter sent to Hanson's GP following the clinic does not detail the risks and benefits of surgery; (5) The 'capacity assessment proforma' does not have a box to Iill in the date, nor a box for the clinician's signature, or the signature of others consulted during the capacity assessment process; (6) The 'best interests proforma' does not have a box to fill in the date, nor a box for the clinician's signature, Or the signature of other consulted during the capacity assessment process; The best interests proforma' contains five boxes on the final page: "consideration of the person's beliefs and values that would have been likely to influence [their] decision if [they] had capacity; relevant circumstances [they] would take into account were making the decision themselves; the identified risks of the proposed treatment and any alternative treatments; the identified benefits of the proposed treatment and any alternative available treatments; the outcome of the best interest assessment; which should demonstrate the weighing of infomation, reasons for discounting particular point of view or the manner in which weight has been applied to certain views: It should demonstrate your analysis and findings as the named decision maker: These questions are clearly central to the best interests assessment, yet they had not been completed by the Staff Nurse carrying out the assessment and were all lelt entirely blank; (8) Given that GMC guidance on consent is that if a discussion regarding treatment is to be delegated, the person to whom that task is delegated must be suitably trained and qualified, have sufficient knowledge of the proposed treatment and understand the risks involved, it is doubtful whether & staff nurse is likely to be the appropriale person to complete the proforma and take such a decision; (9) When undertook the consent process o the of surgery using Consent Form 4, he did not notice that the boxes on the best interests profora had not been completed; (10)Consent 4 does not contain a section for the clinician to carry out the best interests assessment;, and in particular does not have anywhere to Iist the risks and benetits of treatment;, or the balancing of the two, something which bothb and Ithought it should:
Report sections
Investigation and inquest
On 18 August 2014 commenced an investigation into the death of Mary Anne Gemma Hanson, 74 years of age. The investigation concluded at the end of the inquest on 15 April 2015. The conclusion of the inquest was that Mary Anne Gemma Hanson died as a result of rare but recognised complications of appropriate surgery, when she developed intraventricular haemorrhage due to postoperative apoplexy in brain invasive pituitary adenoma, which had been operated on by way of transphenoidal debulking surgery on 27 June 2014.
Circumstances of the death
Hanson was admitted to Royal Preston Hospital 27 June 2014 for elective surgery to remove a large pituitary tumour Although the procedure itself was routine, other than for cerebrospinal fluid leak, which was repaired, she developed bleed post-operatively, which, despite the insertion of an external ventricular drain and a re-exploration of the tumour; she failed to recover and she died on 15 August 2014. Hanson had been_seen in combined pituitary clinic by consultant neurosurgeon, and consultant endocrinologist on 2 June 2014 , following which clinic letter was dictated by At some prior to surgery, 'capacity assessment profoma' and 'best interest proforma' were tilled in by Staff Nurse by reason of the fact that it was considered Hanson lacked capacity to make a decision about the need for surgery due t0 her inability t0 retain information. Following that assessment, consent was taken by neurosurgical registrar, using a 'Consent Form 4' for adults who are unable to consent themselves
Action should be taken
Mary very Mary they day_ key Fon
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action_ YouR RESPONSE You are under a duty l0 respond t0 this report within 56 days of the date of this report, namely by 16 June 2015. !, the area coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action_ YouR RESPONSE You are under a duty l0 respond t0 this report within 56 days of the date of this report, namely by 16 June 2015. !, the area coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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Report details
- Reference
- 2015-0148
- Date of report
- 21 April 2015
- Coroner
- Claire Hammond
- Coroner area
- Preston and West Lancashire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Jun 2015.
Sent to
- Lancashire Teaching Hospital