Source · Prevention of Future Deaths

Katie Davies

Ref: 2014-0255 Date: 6 Jun 2014 Coroner: Alan Walsh Area: Manchester (West) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified concerns about previously unknown 'blind spots' in hospital bleeper systems that could delay emergency responses, and the absence of a policy for prompt transfer of Cerebral Venous Sinus Thrombosis patients to regional neuroscience centres for specialised treatment.

Date 6 Jun 2014

56-day deadline 1 Aug 2014 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified concerns about previously unknown 'blind spots' in hospital bleeper systems that could delay emergency responses, and the absence of a policy for prompt transfer of Cerebral Venous Sinus Thrombosis patients to regional neuroscience centres for specialised treatment.

View full coroner's concerns

During the Inquest evidence was heard that:- In the course of investigations at the Royal Albert Edward Infirmary , Wigan, in relation to the failure of Doctors to respond to contact by use of the internal bleeper system during the deceaseds_admission it was_discovered that there were two 24th blind or blank spots within the precincts of the Hospital, where bleepers could not be activated: The blind or blank spots were previously unknown but were rectified so that bleepers can now be activated within all precincts of the Hospital; Evidence was given that it is believed that similar problems may exist at other Hospitals in the United Kingdom and Hospitals may be unaware of the existence of blind or blank spots within the Hospital. I have concerns that if blind or blank spots exist within Hospitals that there would be in the response of Clinicians to emergencies and patients requiring urgent treatment and in my opinion there is a risk that future deaths will occur unless action is taken: Expert evidence was considered at the Inquest from a Consultant Neurosurgeon at Salford Royal Hospital and Consultant Neurologists from London Edinburgh and Liverpool: The Experts agreed that, on the balance of probabilities, the deceased would have died when she did irrespective of her management after her admission to Royal Albert Edward Infirmary, Wigan on the 22nd December 2012. However , evidence was given that in parts of the United Kingdom, and in particular in London and Cambridge, the management of patients diagnosed with Cerebral Venous Sinus Thrombosis involved the transfer patients from District General Hospital to Regional Neuroscience Centre, as soon as reasonably practicable after a confirmed diagnosis to, allow the patient to receive treatment in Regional Centre where Specialties and Sub-Specialties exist; indluding Consultant Neurosurgeons, Consultant Neurologists and Consultant Neuroradiologists together with appropriate resources and facilities available on a 24 hour a year basis: The evidence confirmed that the treatment of Venous Thrombosis or Venous Stroke is different to the treatment f Cerebral Artery Thrombosis or Cerebral Stroke; The Experts agreed that the treatment of Cerebral Venous Sinus Thrombosis requires initial anticoagulation treatment and monitoring with regular neurological examinations ad neurological observations and, where there is significant deterioration, invasive procedures should be considered including Thrombolysis, Thrombectomy or Clot Extraction and Craniectomy, which can only be carried out at a Regional Neuroscience Centre iii_ Following the deceased's death, a full investigation in relation to the treatment of patients with Cerebral Venous Sinus Thrombosis was conducted by [ Consultant Neurologist and Clinical Director of Medical Neurosciences at Salford Royal Hospital_ together with Consultant delay the day day who

Neurologist Specialising in Cerebrovascular Diseases has produced policy and guidelines for the assessment and management of adult patients with Cerebral Venous Thrombosis in Greater Manchester , a copy of which is attached hereto. The document is extensive and refers to expectation that all patients suffering Cerebral Venous Thrombosis will be transferred from the District General Hospital to the Regional Medical Neuroscience Centre after a confirmed diagnosis of the condition to enable the patient to have the benefit of the Specialties, resources, facilities and invasive procedures only available at the Regional Centre: The evidence at the Inquest indicated that policies and quidelines similar to those produced by_ do not exist in parts of the United Kingdom: In my opinion, there is a risk that future deaths will occur unless action is taken to review the policy and guidelines for the assessment, management and treatment of patients suffering Cerebral Venous Thrombosis in all parts of United Kingdom: [ request you to consider the above concerns and to carry out a review with regard to the following: - The bleeper systems in all Hospitals in the United Kingdom to consider whether blind spots Or blank spots exist within the precincts of Hospitals to ensure coverage of all areas of each Hospital the Iocal bleeper system to enable response ad appropriate action by Clinicians in relation to bleeper calls at all times_ The policy and guidelines for assessment, management and treatment of patients diagnosed with Cerebral Venous Thrombosis in all areas of the United Kingdom, particularly with regard to the diagnosis of the condition and the transfer of patients from a District General Hospital to Regional Medical Neuroscience Centre, as soon as practicable, after a confirmed diagnosis to enable patients to have the benefit of the Specialties, resources, facilities and invasive procedures, which are only available at Regional Centre:

Responses

1 respondent

Department of Health

Central Government

Letter dated 26 Nov 2014 PDF

AI-classified response stance Action Planned

AI-generated response summary

• A safety alert will be sent to all Trusts in England regarding potential blind spots in bleeper systems. • The National Clinical Director for Stroke at NHS England will ask for the issues raised to be reviewed for the next edition of the National Clinical Guidelines for Stroke. • The Coroner's concerns were passed to the Centre for Clinical Practice Director at NICE for information.

View full response

Dear Mr Walsh UlA Our ref: Thank you for your letter to about her response to your Regulation 28 report on the death of Katie Davies: am responding on her behalf. Firstly, please accept my apologies for the delay in my response while discussed the issues raised in your letter of 18 September with colleagues across the Department Your letter requested that, all trusts to be made aware of the issue of potential 'blind spots' for bleepers and pagers on their estates; and the next edition of the National Clinical Guidelines for Stroke consider the concerns you have raised: It may be useful for me to explain that individual Trusts are responsible for their own operations and the Department of Health does not have a "command and control" function_ While individual Trusts remain responsible for their technology and protocols; we recognise the salient points you have raised and have considered how we might raise awareness within the bounds of our remit. Mv .

We have talked to colleagues in NHS Estates and Facilities about this have agreed that a safety alert will be sent to all Trusts in England making them aware of the concerns that you have raised about potential blind spots, and asking them to investigate and take action where necessary: We will also ask that the devolved nations are included in this alert, although you will appreciate that we are not responsible for the NHS outside England. On the issue of clinical guidance in the area of stroke (incorporating Cerebral Venous Sinus Thrombosis), we have again consultede National Clinical Director for Stroke at NHS England. He has agreed to ask for the issues you raise to be reviewed as part of the process of developing the next edition of the National Clinical Guidelines for stroke Additionally, although NICE have no plans at the moment to update their quidelines on acute stroke, we have also passed the Coroner's concerns to who is Centre for Clinical Practice Director at NICE, for information: We thank you for your diligence in this case and that I hope that this response is useful

Report sections

Investigation and inquest

On 278 December 2012 I commenced an investigation into the death of Katie Louise Davies, 21 years, born on gt October 1991. The investigation concluded at the end of the inquest on 2014. The medical cause of death was 1a Massive Cerebral Venous Sinus Thrombosis: The conclusion of the inquest was Katie Louise Davies died as a consequence of Cerebral Venous Thrombosis arising from a combination of naturally occurring inflammatory bowel disease and the use of oral contraception:

Circumstances of the death

1. Katie Louise Davies died at the Royal Albert Infirmary, Wigan on the 26t December 2012.
2. Katie was using oral contraception and in the summer of 2012 she was diagnosed as suffering Crohn's Disease, which is a inflammatory bowel disease. She was prescribed Humira by injection for the treatment of Crohn's Disease.
3. On the 22nd December 2012 the deceased started to feel unwell whilst shopping at the Trafford Centre, Manchester and, later the same she attended at the Accident and Emergency Department at the Royal Albert Edward Infirmary, Wigan with a history of severe headache a vomiting: She had a CT scan which revealed a Cerebral Venous Sinus Thrombosis and the diagnosis was confirmed by a CT venogram on the following day: the 22nd May` from day,

When the CT venogram confirmed the diagnosis the deceased was referred to the Regional Centre for Medical Neurosciences at Salford Royal Hospital, Salford for advice in relation to treatment of the Cerebral Venous Sinus Thrombosis and further advice as to whether the deceased should be transferred to the Regional Centre at Salford Royal Hospital for treatment 4_ The Neurology Registrar at Salford Royal Hospital supported by the Consultant Neurologist on call, advised treatment with low molecular weight Heparin and Warfarin, as anticoagulant treatment, with regular neurological examinations including fundoscopy and visual fields. The advice was that the deceased should be treated at the District General Hospital namely the Royal Albert Edward Infirmary in Wigan and the Regional Unit at Salford Royal Hospital should be contacted for further advice if needed: The purpose of regular neurological examinations was to observe the patient for signs of neurological deterioration: Further advice was given that the deceased should be referred to the visiting Neurologist at the Royal Albert Edward Infirmary , Wigan
5. On the December 2012 the Regional Centre for Medical Neurosciences at Salford Royal Hospital was contacted by Clinician from the Royal Albert Edward Infirmary, Wigan in relation to whether the deceased should be discharged from hospital as there were no available Neurologists visiting the Hospital for two weeks_ The Neurology Registrar at Salford Royal Hospital was informed by the Clinician that the deceased remained clinically stable without any neurological deterioration and the Registrar advised that the deceased should remain in Hospital at Wigan until her symptoms settled and until she was on a therapeutic warfarin dose:
6. The deceased remained at the Royal Albert Infirmary, Wigan and, although she showed some signs of deterioration on the 25t December 2012, her observations were stable until she was found unresponsive on the 26th December 2012 at 7.20am when she had a cardiac arrest and died;

Action should be taken

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

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Report details

Reference: 2014-0255
Date of report: 6 June 2014
Coroner: Alan Walsh
Coroner area: Manchester (West)

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: 1 Aug 2014 (estimated from the report date).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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