Robert Perkins

North Bristol NH NHS Trust Trust Headquarters Southmead Hospital Bristol Southmead Road Westbury-on- Bristol BS1O SNB Tel:0117 41 43816 Websile: http IlwWW nbLIhs uk 20 June 2014 Dr P Harrowing HM Assistant Coroner The Coroner's Court The Courthouse Old Weston Road Flax Bourton BS48 1UL By Fax 01275 462749 Robert Anthony Perkins (deceased) 36 Kipling Road; Northville, Bristol DOB: 7/12 1943 DOD: 16/6/2013 refer to the Regulation 28 report dated 28h April 2014 following the inquest into the death of Mr Perkins, which concluded on the 2Ist March 2014. From investigations it appears that whilst in the Emergency Department (ED) Mr Perkins was too agitated to wear a rigid collar and persistence in trying to put a collar on or even just wearing & collar would likely to have caused more harm and distress to him: Also the ED consultant felt it inappropriate to sedate Mr Perkins for the purposes of applying the collar, again due to the risks of harm from sedation. In the ED there were 2 separate attempts at putting a collar on firstly a hard collar was attempted and then, later on, a Philadelphia collar (significantly more comfortable than hard collars thus better tolerated) Mr Perkins did not tolerate either_ There was a clear decision made by the ED team that they should not persist further in applying a collar: What was not clear was how this was communicated across to the receiving medical team especially with respect to the absolute need for the collar, if this could be tolerated by Mr Perkins, and the timing for attempting to reapply the collar. Following review, the ED matron had discussed this communication failure with the nursing team concerned It is clear that communication of these issues is vital to prevent a recurrence of & similar case It is agreed that communication should include, where there is a failure to apply a rigid collar in the ED, the reasons why the collar was not applied and the nursing aspects for the neck in the interim and when a reattempt at applying the collar should occur_ Since move to the new hospital at Southmead change has occurred in process regarding overall responsibilily for patients Now Acute Admissions Unit (AAU) consultants are in charge of the medical intake 24/7 , (previously the on consullant was in charge in lieu of an acute physician) so there is a clearer of responsibility there is an AAU consultant (i.e. acute physician) on site between 8 am and 10 pm and on call overnight as Peter Rilett Unlverslty of Bristol Teaching Trust Andrea Young Chairman University of the of England Teachlng Trust Chief Executive Trym the call line West

of this Is that there is much less variance in terms of clinicians with overall well, The effect responsibility, now only 8 rather than the previous 24 clinicians. the Clinical Director (CD) of the Medicine Directorate discussed this Following the inquest in particular awareness and understanding regarding case will his neurosurgical colleagues dated October 2011_ The CD will re- the use of collars_ enclose a hard collar safety alert and to other puebliciseothis issue by sending this alert out again to the cedicadDyreafodaaesc include it in Sfhat there is Trustwide distribution in the next few days and also CDs t0 ensure medical staff (Ihe next one will be in August 2014) future medical induction of new collars for the purposes of cervical immobllisation is something that The accessibilily of rigid into the new Brunel building: A place for is also being readdressed now since the movee Zone. By creating centfai storage of these devices is being looked for within the Emeseency where to find location of these devices it should make it easier t0 know single area for the anticipated that this action should be completed by a collar when the device is needed It is the end of June 2014. will also be reported on in part B of the Medical Directorate's clinical The regulation 28 report 2OtepFrom here it will be decided on whether any further governance agenda on 26 June further notification will be made to action needs to be taken; Following this, it is likely that a need to review medical teams to ensure that they are all familiar with the the directorate's is admitted with cervical neck injury and plans for cervical immobilisation when a the location of the rigid collar devices_ exceptional case in the Medical Directorate;
i.e., a dying In conclusion, Mr Perkins was an have collar fitted in ED, for the man who was confused and difficult to manage who did suffer further above_ However , agree it was fortuitous he did not reasons explained substandard in AAU, and trust the implementation of disability, that his management was similar issues in the future. the above will prevent a recurrence of these or