Joan Sanderson
PFD Report
Partially Responded
Ref: 2020-0198
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
22 Jan 2021
Over 2 years old — no identified published response
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
The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Responses
Response received
View full response
Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths Joan Margaret Sanderson
15.06.2020 Thank you for your Regulation 28 Report dated 5 October 2020 concerning the death of Joan Margaret Sanderson on 15 June 2020. Firstly , would like t0 express my deep condolences to Joan Margaret Sanderson's family: The inquest concluded that Joan Margaret Sanderson's death was a result of cardiopulmonary arrest; 1b) MRSA positive left hip metalwork infection; 2) Dementia, Diabetes mellitus. Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding that there was no requirement for MRSA swabbing of patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result: Whilst surgery would not have been delayed awaiting the outcome of results, it could impact the outcome in another case where emergency surgery is required and there is an infection post-operatively have noted that your Regulation 28 letter has also been sent to HSIB ad will leave it to the named respondent to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP. Geater Manchester Health and Social Care Partriership is made up of allthe NHS orgarisatians and counciis in thr? City region: We re overseeinr] devolution and charge of thie EGbn health and social czre budget WWW ginhsc org uk Ia) Takirg
Summary of actions taken or being taken by the organisation involved: The Trust confirmed that; The MRSA Policy was updated in February 2019 to align with national screening guidance around MRSA screening of patients from other hospitals, nursinglresidential homes, or those that have had a previous positive screenlclinical sample result on admission is undertaken Actions taken or being taken to prevent reoccurrence across Greater Manchester. Learning to be presentedlshared with the Greater Manchester Quality Board: This meeting is attended by commissioners , including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services commission 3 Learning to be shared with the Greater Manchester Infection Prevention and Control Collaborative for members to take into their provider organisations to ensure that national screening guidance is being followed Findings to be also shared with the Northwest NHS Englandllmprovement Infection prevention for consideration of sharing across the Northwest The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester . In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information: Yours sincerely Chair of GM Medical Executive, GMHSCP Greater Manchester Health and Social Care Partnership I5 inarle up of all the NHS organisations and councils in the city region We rc oversecing dcvolution and taking charge of the EGbn health and social care budget. WWW grnhsc org uk they KW
HSIB HEaLthcare SAfEtY nvestigatiom BRANch 27 November 2020 HEALTHCARE SAFETY INVESTIGATION BRANCH HSIB A1 Alison Mutch OBE Cody Technology Park HM Senior Coroner Farnborough Coroner s Court Hampshire 1 Mount Tabor Street GU14 OLX Stockport SK1 3AG Dear Ms Mutch, RE: Regulation 28: Report To Prevent Future Deaths. The death of Joan Margaret Sanderson on 15 June 2020 Thank you for contacting HSIB regarding prevention of future deaths report regarding Joan Margaret Sanderson dated 5 October 2020. Following careful consideration; we will not be taking forward an investigation into your concerns_ We are only able to undertake a limited number of national investigations each year, and therefore try to focus on those with the most potential for new learning across the NHS. The National Criteria for selection is described on our website: https Ilwwwhsiborg uklpublic-patients/how-we-decide t0-investiqatel We do not underestimate the seriousness of your concerns and may consider this issue again in the future as further information becomes available. The information that you have shared with us is important, even ifwe do not start an investigation as a result: Everything we receive is added to our database, whether we start an investigation or not As it grows, our database builds picture of risk in healthcare and allows us to identify recurring problems and patterns_ Should we wish to contact you in the future regarding this information, it would if we store the personal details you have given US, if this is acceptable to you: If you prefer that we do not keep your details, please let us know and we will ensure that they are removed from our database in accordance with our privacy notice (https IWhsiborg Uklprivacyl) Once again, thank you for contacting us and we are sorry that we are not able to take this forward
15.06.2020 Thank you for your Regulation 28 Report dated 5 October 2020 concerning the death of Joan Margaret Sanderson on 15 June 2020. Firstly , would like t0 express my deep condolences to Joan Margaret Sanderson's family: The inquest concluded that Joan Margaret Sanderson's death was a result of cardiopulmonary arrest; 1b) MRSA positive left hip metalwork infection; 2) Dementia, Diabetes mellitus. Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding that there was no requirement for MRSA swabbing of patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result: Whilst surgery would not have been delayed awaiting the outcome of results, it could impact the outcome in another case where emergency surgery is required and there is an infection post-operatively have noted that your Regulation 28 letter has also been sent to HSIB ad will leave it to the named respondent to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP. Geater Manchester Health and Social Care Partriership is made up of allthe NHS orgarisatians and counciis in thr? City region: We re overseeinr] devolution and charge of thie EGbn health and social czre budget WWW ginhsc org uk Ia) Takirg
Summary of actions taken or being taken by the organisation involved: The Trust confirmed that; The MRSA Policy was updated in February 2019 to align with national screening guidance around MRSA screening of patients from other hospitals, nursinglresidential homes, or those that have had a previous positive screenlclinical sample result on admission is undertaken Actions taken or being taken to prevent reoccurrence across Greater Manchester. Learning to be presentedlshared with the Greater Manchester Quality Board: This meeting is attended by commissioners , including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services commission 3 Learning to be shared with the Greater Manchester Infection Prevention and Control Collaborative for members to take into their provider organisations to ensure that national screening guidance is being followed Findings to be also shared with the Northwest NHS Englandllmprovement Infection prevention for consideration of sharing across the Northwest The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester . In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information: Yours sincerely Chair of GM Medical Executive, GMHSCP Greater Manchester Health and Social Care Partnership I5 inarle up of all the NHS organisations and councils in the city region We rc oversecing dcvolution and taking charge of the EGbn health and social care budget. WWW grnhsc org uk they KW
HSIB HEaLthcare SAfEtY nvestigatiom BRANch 27 November 2020 HEALTHCARE SAFETY INVESTIGATION BRANCH HSIB A1 Alison Mutch OBE Cody Technology Park HM Senior Coroner Farnborough Coroner s Court Hampshire 1 Mount Tabor Street GU14 OLX Stockport SK1 3AG Dear Ms Mutch, RE: Regulation 28: Report To Prevent Future Deaths. The death of Joan Margaret Sanderson on 15 June 2020 Thank you for contacting HSIB regarding prevention of future deaths report regarding Joan Margaret Sanderson dated 5 October 2020. Following careful consideration; we will not be taking forward an investigation into your concerns_ We are only able to undertake a limited number of national investigations each year, and therefore try to focus on those with the most potential for new learning across the NHS. The National Criteria for selection is described on our website: https Ilwwwhsiborg uklpublic-patients/how-we-decide t0-investiqatel We do not underestimate the seriousness of your concerns and may consider this issue again in the future as further information becomes available. The information that you have shared with us is important, even ifwe do not start an investigation as a result: Everything we receive is added to our database, whether we start an investigation or not As it grows, our database builds picture of risk in healthcare and allows us to identify recurring problems and patterns_ Should we wish to contact you in the future regarding this information, it would if we store the personal details you have given US, if this is acceptable to you: If you prefer that we do not keep your details, please let us know and we will ensure that they are removed from our database in accordance with our privacy notice (https IWhsiborg Uklprivacyl) Once again, thank you for contacting us and we are sorry that we are not able to take this forward
Report Sections
Investigation and Inquest
On 15th June 2020 I commenced an investigation into the death of Joan Sanderson. The investigation concluded on the 4th September 2020 and the conclusion was one of Narrative: Died from complications of a surgical procedure following an accidental fall. The medical cause of death was 1a) Cardiopulmonary arrest; 1b) MRSA positive left hip metalwork infection; II) Dementia, Diabetes mellitus
Circumstances of the Death
Joan Margaret Sanderson had an accidental fall. She was admitted to Tameside General Hospital where a displaced intertrochanteric fracture of the left hip was diagnosed. She was operated on. She developed an infection which was identified as MRSA. She deteriorated and died on 15th June 2020 at Tameside General Hospital.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.