Source · Prevention of Future Deaths

Neil Westerman

Ref: 2015-0091 Date: 11 Mar 2015 Coroner: John Pollard Area: Manchester (South) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryA junior doctor performed the pre-operative assessment, leading to the consultant being unaware of vital information, and operation notes lacked details of equipment used. There were also insufficient junior doctors on duty, particularly at night.

Date 11 Mar 2015

56-day deadline 6 May 2015 stated in the report

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

A junior doctor performed the pre-operative assessment, leading to the consultant being unaware of vital information, and operation notes lacked details of equipment used. There were also insufficient junior doctors on duty, particularly at night.

View full coroner's concerns

1. During the course of the inquest heard evidence that the pre-operative assessment was performed by a junior doctor and not by the consultant who was to perform the procedure: This meant that the consultant was unaware of certain vital information: The operation notes did not contain details of the equipment and materials used during the procedure and it was agreed that this should be the case and that all such items should be fully recorded and accounted for at the conclusion of the procedure.
3. heard evidence, as have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren't enough doctors available: 20t_ Biliary

Responses

1 respondent

Stockport NHS Trust

NHS Trust

Letter dated 27 Apr 2015 PDF

AI-classified response stance Action Taken

AI-generated response summary

• Steps were taken with the individual surgeon to prevent a recurrence of non-standard pre-operative assessments, and the case was discussed at a Morbidity & Mortality meeting and with the junior doctor. • The requirement for vigilance in documenting equipment details in operating notes was reiterated across the Surgery and Critical Care Business Group. • A review of general surgical junior doctor rotas is underway, aiming for increased presence on the surgical assessment unit and a more even spread of doctors, with consideration also given to broadening advanced nurse practitioner roles by August 2015.

View full response

Dear Mr Pollard, Re: Neil Thomas Westerman (Deceased) Thank you for your letter of 11mh March 2015, concerning the inquest of the above named. As always am grateful to you for highlighting your concerns on the Regulation 28 'Report to prevent future deaths and for providing me with an opportunity to respond. am able to address your areas of concern as follows: Aconcern_regarding the pre-operative assessment being_carried out_ bY a junior doctor and pot _the consultant who was to perform the operation_meaning the consultant was_ unaware of vital information This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation_ The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment The_operating_notes did not contain_details_of_the_equipment and materials_used during_the procedure: In this case this was an error; it is standard practice to document and record all relevant information for the related surgery, including the recording of equipment and the numbers Of items used, In this case there was clearly an omission to record such details and the requirement for vigilance in this respect has been reiterated across the Surgery and Critical Care Business Group: Despite_numbers being_in compliance_with set_quidelines_there were_too few junior doctors on duty to cover_the needs of the patients: We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week_ Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competence and skills to out many of the basic junior doctor roles_ The plan is to have these changes in place by the end of August 2015. hope that this response answers your concerns and provides you with assurance that the Trust is committed to improving the quality of care we give to all our patients Please do not hesitate to contact me if you have any further questions regarding this matter.

Report sections

Investigation and inquest

On the 10"h July 2014 commenced an investigation into the death of Neil Thomas Westerman dob June 1942 The investigation concluded on the 5"h January 2015 and the conclusion was one of misadventure. The medical cause of death was Ia Multi system organ failure 1b Septicaemia 1c leak following laparoscopic abdominal surgery.

Circumstances of the death

On the 2nd July 2014 he attended Stepping Hill Hospital for an elective cholecystectomy: The operation led to a leakage of bile causing septicaemia

Action should be taken

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

Similar PFD reports

Shared signals

Report details

Reference: 2015-0091
Date of report: 11 March 2015
Coroner: John Pollard
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: 6 May 2015 (stated in the report).

Sent to

Stockport NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.