James Sheffield
PFD Report
All Responded
Ref: 2018-0214
All 1 response received
· Deadline: 7 Jun 2018
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
7 Jun 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.
Responses
Response received
View full response
Dear Sir Re: James Sheffield Response to Regulation 28 Report write further to the Inquest into the death of Mr Sheffield which concluded on 31 January
2018. acknowledge receipt of the Regulation 28 report that was subsequently issued on 12 April 2018 and note the concerns outlined: As you are aware, following the conclusion of the Inquest, the Trust wrote to You on 2 February 2018 (a signed copy of the letter was subsequently dated 7 February 2018) in order to outline the prompt action that the Trust had already taken in response to the concerns which you raised at the Inquest. enclose a further copy of that letter, together with the enclosures, as the Trust's formal response to the Regulation 28 Report. trust that the information provided assures you of the prompt action taken by the Trust to ensure that your concerns were swiftly addressed. Please let me know if you require any further information. Yours faithfully Medical Director 17th
HILL DICKINSON HM Coroner for Manchester West Your Ref: Mr T Brennand Our Ref: 1093708.211,JT.JCRI HM Coroner's Court Doc Ref: 151239355.1 Date: 07 February 2018 Paderborn House Civic Centre Howell Croft North Bolton BL 1 1 QY Dear Sir Re: James Sheffield write on behalf of my colleague, Joanna Crichton: Further to the assurances given by at the Inquest into the death of James Sheffield which concluded on Wednesday 31 January 2018, the Trust has already now implemented further changes to the ward to ward transfer document on its electronic patient record system in order to address the additional concern raised A screenshot of the updated document is attached showing the additional information which must be recorded on all transfers. A box requires confirmation that all essential equipment is available, checked and ready to use. The expectation therefore , is that equipment is set up upon transfer In addition, if "yes is selected, details must be recorded. In the event that "no" is selected an explanation must be recorded to explain why this is the case. can confirm that these changes are now live and have been fully implemented. In order to accompany these changes, the Trust has circulated a safety alert to all staff to inform them of the changes to the EPR and the reasons for this A copy of the alert is also attached to this email; In the circumstances; it is clear that the duty to make a Regulation 28 report is no longer engaged since the Trust has already taken steps to put in place measures to prevent the recurrence of the risk identified. Any Regulation 28 report in (hese circumstances would not have any practical effect and accordingly would not comply with the Chief Coroner 's Guidance Number 5 at Paragraph 5. The Coroner is also respectfully reminded of Paragraph 24 of that same guidance. It is a matter for the Trust to determine what the action should be in order to address the concern: The Trust has put in place additional changes to its ward to ward transfer documentation and process which it determines to be the most appropriate method of addressing the concern: HItt Dicklnson LLP No SL Paurs Square hilldickintoncon Llverpool L3 0SJ Tel: +44 (01151 600 8000 HIll Dlcklnton Lequl Senvicet Group hut olicut In Llvampool pedt, Manchester; London; Plratue, Singapore, Monaco and Fax: +44 (0)+51 600 8001 Hong Kong Hil Dickinson LLP Is imilad Iilability partnership (egistarad in England and Wales with registered number 0C314079. Ils regixtered ofica al No: St Pauls Squoro; Liverpool L J 95J Hin DickInson LLP @ authonsed and roguinled by Ina Sollcilors Regulalon Aulhonly The
The Trust takes patient safety seriously and wishes to ensure that lessons are learnt where possible. The Trust has taken on board the additional concern identified and has (aken prompt action to address that concern; In the circumstances; Regulation 28 report would be redundant; Please do not hesitate to contact Joanna Crichton or should you wish to discuss this?
2018. acknowledge receipt of the Regulation 28 report that was subsequently issued on 12 April 2018 and note the concerns outlined: As you are aware, following the conclusion of the Inquest, the Trust wrote to You on 2 February 2018 (a signed copy of the letter was subsequently dated 7 February 2018) in order to outline the prompt action that the Trust had already taken in response to the concerns which you raised at the Inquest. enclose a further copy of that letter, together with the enclosures, as the Trust's formal response to the Regulation 28 Report. trust that the information provided assures you of the prompt action taken by the Trust to ensure that your concerns were swiftly addressed. Please let me know if you require any further information. Yours faithfully Medical Director 17th
HILL DICKINSON HM Coroner for Manchester West Your Ref: Mr T Brennand Our Ref: 1093708.211,JT.JCRI HM Coroner's Court Doc Ref: 151239355.1 Date: 07 February 2018 Paderborn House Civic Centre Howell Croft North Bolton BL 1 1 QY Dear Sir Re: James Sheffield write on behalf of my colleague, Joanna Crichton: Further to the assurances given by at the Inquest into the death of James Sheffield which concluded on Wednesday 31 January 2018, the Trust has already now implemented further changes to the ward to ward transfer document on its electronic patient record system in order to address the additional concern raised A screenshot of the updated document is attached showing the additional information which must be recorded on all transfers. A box requires confirmation that all essential equipment is available, checked and ready to use. The expectation therefore , is that equipment is set up upon transfer In addition, if "yes is selected, details must be recorded. In the event that "no" is selected an explanation must be recorded to explain why this is the case. can confirm that these changes are now live and have been fully implemented. In order to accompany these changes, the Trust has circulated a safety alert to all staff to inform them of the changes to the EPR and the reasons for this A copy of the alert is also attached to this email; In the circumstances; it is clear that the duty to make a Regulation 28 report is no longer engaged since the Trust has already taken steps to put in place measures to prevent the recurrence of the risk identified. Any Regulation 28 report in (hese circumstances would not have any practical effect and accordingly would not comply with the Chief Coroner 's Guidance Number 5 at Paragraph 5. The Coroner is also respectfully reminded of Paragraph 24 of that same guidance. It is a matter for the Trust to determine what the action should be in order to address the concern: The Trust has put in place additional changes to its ward to ward transfer documentation and process which it determines to be the most appropriate method of addressing the concern: HItt Dicklnson LLP No SL Paurs Square hilldickintoncon Llverpool L3 0SJ Tel: +44 (01151 600 8000 HIll Dlcklnton Lequl Senvicet Group hut olicut In Llvampool pedt, Manchester; London; Plratue, Singapore, Monaco and Fax: +44 (0)+51 600 8001 Hong Kong Hil Dickinson LLP Is imilad Iilability partnership (egistarad in England and Wales with registered number 0C314079. Ils regixtered ofica al No: St Pauls Squoro; Liverpool L J 95J Hin DickInson LLP @ authonsed and roguinled by Ina Sollcilors Regulalon Aulhonly The
The Trust takes patient safety seriously and wishes to ensure that lessons are learnt where possible. The Trust has taken on board the additional concern identified and has (aken prompt action to address that concern; In the circumstances; Regulation 28 report would be redundant; Please do not hesitate to contact Joanna Crichton or should you wish to discuss this?
Report Sections
Circumstances of the Death
The deceased had a history of neuro-ischaemic ulcer to the right foot; dyslipidaemia, angina, previous heart failure, previous stroke, hypertension, obesity hypoventilation syndrome and obstructive sleep apnoea: On the 1st June 2016,the deceased suffered an accidental fall at a shopping day centre: He was taken to Salford Royal Hospital, Eccles Old Road, Salford and following full evaluation was discharged with analgesia upon no significant findings being diagnosed_ On the 13th July 2016, the deceased was recalled to the hospital upon a clinical review revealing potential abnormality and then diagnosed with a hairline femoral fracture and pelvic metastatic carcinoma which was deemed to be secondary to a carcinoma of the kidney: There was a delay between recall, diagnosis and active surgical intervention in the form of corrective hip replacement surgery that took place without complication on the 11t 2016. That had no bearing upon the outcome: Post-operatively, the deceased received high dependence care within an Intensive Care Unit and made an initial recovery to the extent that that he was stood down to care on ward: Upon transfer to ward, the deceased's CPAP machine that was intended to accompany him went missing following X-ray procedures undertaken prior to admission on ward. The accepted omission to ensure an important item of medical equipment was transferred and in the possession of the deceased and available for use did not have a bearing on the outcome; At about 1.15pm on the 12th July 2016, suddenly and unexpectedly, for reasons that cannot be established, the deceased suffered a cardio-respiratory arrest; Resuscitation was undertaken promptly. Despite active management of his condition, the deceased failed to regain consciousness. His condition deteriorated until he died on the 170 July 2016.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.