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Rosa Anderson

Ref: 2013-0263 Date: 17 Oct 2013 Coroner: Andre Rebello Area: Liverpool Responses identified: 1 / 1 View PDF

The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.

Date 17 Oct 2013
56-day deadline 12 Dec 2013
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
View full coroner's concerns
In the circumstances it js _my statutory duty to report to_YQU The day: May

_ During the course of the Inquest it was evident that Mrs Anderson was not given a discharge summary when discharged on 30" April 2013. Further; she was given no written information about her recent laparoscopic operation, contact telephone numbers for advice, nor were matters highlighted that required urgent medical assistance_

Responses

1 respondent
Aintree University Hospital NHS / Health Body
10 Dec 2013 PDF
Action Taken

Aintree University Hospital has implemented a discharge advice sheet for laparoscopic procedures and is providing generic leaflets for all discharged patients, with specialties developing individualized discharge information sheets by March 2014. (AI summary)

View full response
Dear Sir

Re: Patient RA Ref DR 01152/2013 write in response to your Regulation 28 Report of 18 October 2013 regarding the failure to provide written discharge information to the patient following a laparoscopic surgical procedure, including contact details for advice and action to be taken in the event of urgent medical assistance being required: can confirm that there is now a discharge advice sheet in place , appropriate for these laparoscopic procedures and this is provided to all relevant patients prior to discharge. This discharge advice is generic for patients undergoing short stay surgery: There is also a separate patient information leaflet for patients having hiatus hernia surgery and this is given to patients pre- operatively. This also includes discharge advice for that specific group of patients. Action is also taken to ensure that appropriate written advice is provided to all inpatients of the Trust (both Surgical and Medical) to discharge. A number of generic leaflets have been produced intending to cover all patients on discharge where a procedure specific information leaflet is not available. This will be implemented by 1 January 2014_ In addition, a number of specialties are looking at developing their own individualised discharge information sheets and action is taken to ensure that in such cases this is implemented by March 2014. In the meantime, in such cases, the appropriate generic information leaflet will be provided to the patient:

Report sections

Circumstances of the death
On 29th April 2013, Rosa Anderson underwent a laparoscopic repair of a diaphragmatic hernia at the University Hospital Aintree. During the procedure, damage was inadvertantly caused to the oesophagus within the thorax There was no way this could have been appreciated at the time. The following day, Mrs Anderson was discharged home_ The same evening she was admitted to the emergency department with abdominal pain and burning in the epigastric region. From the signs and symptoms, the breach of the oesophageal wall was not appreciated_ She was referred to the surgical team and a CT Scan was arranged for the next With hindsight, the fact that the leaking oesophagus was not detected earlier lessened the chances of a successful resolution The leaking oesophagus caused mediastenitis, which compromised Mrs Anderson's breathing: This led to a cardiac arrest and hypoxic brain injury on Zth
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:

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Report details

Reference
2013-0263
Date of report
17 October 2013
Coroner
Andre Rebello
Coroner area
Liverpool

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: 12 Dec 2013.

Sent to

Aintree Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.