Rita Flynn
PFD Report
All Responded
Ref: 2022-0310
All 1 response received
· Deadline: 3 Oct 2022
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Response Status
Responses
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56-Day Deadline
3 Oct 2022
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. Evidence emerged during the inquest that there were clear indicators of an infection and before being discharged home by the hospital, it would have been best practice to wait for the blood tests results.
Responses
Response received
View full response
Dear Mr Siddique
Inquest – Ms Rita Flynn – deceased
I refer to the death of patient Ms Flynn, this matter was heard before your court following an inquest hearing on the 20th June 2022. I am writing to you to respond to the Regulation 28 Notice to received on the 16th August 2022, addressed to the Trust’s Chief Executive.
As Chief Medical Officer, I have instructed the Directorate Management team within the Emergency Department to attend to your concerns raised upon hearing the evidence and more importantly in conjunction a joint plan of actions has been drafted attending to the issue as discharge of patients without blood test results in particular, where such results are indicative as to an infection. In response the Divisional team have attended to the specific tasks raised to address the following:
1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.
2. In addition, where test results show evidence of infection and the patient has been discharged home, then consideration should be given to contacting the patient at home urgently for follow up review.
Review of policy/discharge guidance
• Training There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level. Senior Consultants within the team who deliver individual training needs, as such will disseminate to postgraduate staff the importance of reviewing blood results in adhering to discharge protocol.
• Documentation An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.
• Electronic recording/Systems Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours). The above process and plans were agreed following a Divisional meeting held on the 5th September 2022 and Governance meeting held on the 27th September 2022. The process will be included within the ED policy/guidance for the discharge of patient pathway.
I attach for your attention an action plan devised by the team. The actions have been addressed and evidence of actions conducted will follow shortly.
Inquest – Ms Rita Flynn – deceased
I refer to the death of patient Ms Flynn, this matter was heard before your court following an inquest hearing on the 20th June 2022. I am writing to you to respond to the Regulation 28 Notice to received on the 16th August 2022, addressed to the Trust’s Chief Executive.
As Chief Medical Officer, I have instructed the Directorate Management team within the Emergency Department to attend to your concerns raised upon hearing the evidence and more importantly in conjunction a joint plan of actions has been drafted attending to the issue as discharge of patients without blood test results in particular, where such results are indicative as to an infection. In response the Divisional team have attended to the specific tasks raised to address the following:
1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.
2. In addition, where test results show evidence of infection and the patient has been discharged home, then consideration should be given to contacting the patient at home urgently for follow up review.
Review of policy/discharge guidance
• Training There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level. Senior Consultants within the team who deliver individual training needs, as such will disseminate to postgraduate staff the importance of reviewing blood results in adhering to discharge protocol.
• Documentation An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.
• Electronic recording/Systems Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours). The above process and plans were agreed following a Divisional meeting held on the 5th September 2022 and Governance meeting held on the 27th September 2022. The process will be included within the ED policy/guidance for the discharge of patient pathway.
I attach for your attention an action plan devised by the team. The actions have been addressed and evidence of actions conducted will follow shortly.
Action Should Be Taken
1. You may wish to consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection indicated.
2. In addition, where test results indicate evidence of infection and the patient has been discharged home, then consideration should be given to contacting the patient at home urgently for follow up review.
2. In addition, where test results indicate evidence of infection and the patient has been discharged home, then consideration should be given to contacting the patient at home urgently for follow up review.
Report Sections
Investigation and Inquest
On the 30 May 2022, I commenced an investigation into the death of Mrs Rita Flynn. The investigation concluded at the end of the inquest on the 20 June 2022. The conclusion of the inquest was a narrative conclusion as follows:
The deceased died after developing complications arising from a lung abscess.
The cause of death was:
1a Right Upper Lobe Purulent Abscess (no tumour)
The deceased died after developing complications arising from a lung abscess.
The cause of death was:
1a Right Upper Lobe Purulent Abscess (no tumour)
Circumstances of the Death
i) Mrs Flynn was a 78-Year-old woman who contacted her GP after feeling ill with flu like symptoms. She had a telephone consultation on the 12 January 2022. ii) She was given antibiotics and also advised to take a COVID PCR test. Initially her condition improved and the COVID test was negative. iii) Subsequent Blood tests results later revealed that she had raised potassium levels and indicators for infection. She was directed to go to New Cross Hospital for further examination on 20 January 2022. iv) After further tests including x-ray and a CT scan, a differential diagnosis of malignancy or infection was made. She wasn't given any further antibiotics at this stage and effectively discharged home for further follow up treatment. v) By the 3 February 2022 her condition declined further, and she complained of shortness of breath associated with haemoptysis and was taken to New Cross Hospital by ambulance. vi) Further blood tests were taken and before the blood tests results were
[IL1: PROTECT] available she was discharged home on the basis she had a malignancy and didn't require immediate admission to hospital. vii) Blood tests later indicated positive signs of infection. viii) Her condition declined rapidly and sadly she passed away at home on the 4 February 2022.
[IL1: PROTECT] available she was discharged home on the basis she had a malignancy and didn't require immediate admission to hospital. vii) Blood tests later indicated positive signs of infection. viii) Her condition declined rapidly and sadly she passed away at home on the 4 February 2022.
Inquest Conclusion
The deceased died after developing complications arising from a lung abscess.
The cause of death was:
1a Right Upper Lobe Purulent Abscess (no tumour)
The cause of death was:
1a Right Upper Lobe Purulent Abscess (no tumour)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.