Gordon Arthur
PFD Report
All Responded
Ref: 2017-0009
All 1 response received
· Deadline: 16 Apr 2017
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
16 Apr 2017
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
During the inquest evidence was heard that: The Consultant in charge of Mr Arthur's hip operation, and who carried out the surgery, was who is based at Salford Royal NHS Foundation Trust; Following Mr Arthur's discharge from Trafford General Hospital on the August he presented to the Accident and Emergency Department at Salford Royal Hospital on the 25t August as the surgical wound had started to ooze, which can be sign of infection: At that time an ultrasound scan of his hip was requested and the wound was redressed. confirmed the scan should have been done urgently, however it was not carried out until the 1st September
iii. Mr Arthur re-attended the Accident and Emergency department on the following with continued oozing from the surgical wound. The wound was redressed again and he was discharged. iv was not made aware of Mr Arthur's attendance at the Accident and Emergency Department on either the 25th or the 26t August until the 31s August; when he immediately requested that antibiotic therapy be prescribed, which Mr Arthur started taking that night; Had he been made aware of Mr Arthur's condition he would have admitted him on the 25h August for further investigation and treatment The ultrasound scan took place on the 1* September which revealed collection at the surgical site, again indicative of infection The radiologists reported the scan but this was never reviewed and was not made aware of the results;
vi. On the 6th September Mr Arthur was attending his GP for problem with his shoulder when he suffered a cardiac arrest; Fortunately Doctors were on hand to resuscitate him and he was taken to the Salford Royal Hospital where investigations revealed infection at the surgical site: He underwent surgery to wash out his hip that day: He was actively treated for that infection, which at the time of the post mortem examination had resolved 21st`
vii. From the evidence given the in the treatment of the infection at the site of the hip surgery was not, on the balance of probabilitiescausative or contributory to his death: During the evidence confirmed that there is no policy in place at the Trust detailing procedures for the request of investigations, such as scans or X-rays, nor is there policy relating to the notification of the results of such investigations to the Consultant in charge of the patient's care: I have concerns with regard to the following: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient's care could lead to patients not given the treatment require, which could result in a future death; therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to Consultant in charge of the patients care in order to prevent a future death;
iii. Mr Arthur re-attended the Accident and Emergency department on the following with continued oozing from the surgical wound. The wound was redressed again and he was discharged. iv was not made aware of Mr Arthur's attendance at the Accident and Emergency Department on either the 25th or the 26t August until the 31s August; when he immediately requested that antibiotic therapy be prescribed, which Mr Arthur started taking that night; Had he been made aware of Mr Arthur's condition he would have admitted him on the 25h August for further investigation and treatment The ultrasound scan took place on the 1* September which revealed collection at the surgical site, again indicative of infection The radiologists reported the scan but this was never reviewed and was not made aware of the results;
vi. On the 6th September Mr Arthur was attending his GP for problem with his shoulder when he suffered a cardiac arrest; Fortunately Doctors were on hand to resuscitate him and he was taken to the Salford Royal Hospital where investigations revealed infection at the surgical site: He underwent surgery to wash out his hip that day: He was actively treated for that infection, which at the time of the post mortem examination had resolved 21st`
vii. From the evidence given the in the treatment of the infection at the site of the hip surgery was not, on the balance of probabilitiescausative or contributory to his death: During the evidence confirmed that there is no policy in place at the Trust detailing procedures for the request of investigations, such as scans or X-rays, nor is there policy relating to the notification of the results of such investigations to the Consultant in charge of the patient's care: I have concerns with regard to the following: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient's care could lead to patients not given the treatment require, which could result in a future death; therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to Consultant in charge of the patients care in order to prevent a future death;
Responses
Response received
View full response
Dear Mrs Griffin Re: Mr Gordon Arthur (Deceased); Regulation 28: Report to Prevent Future Deaths to Salford Royal NHS Foundation Trust issued on 25th January 2017 . was to hear that you had concerns about future preventable deaths_ You requested that Salford Royal NHS Foundation Trust consider your concerns in relation to: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patients care could lead to patients not being given the treatment they require, which could result in future death: therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to the Consultant in charge of the patient's care in order to prevent a future death: Following receipt of your letter the Clinical Director for Radiology and the Clinical Director for the Orthopaedic service carried out joint review of the current trust policies in relation to the ordering of radiological investigations and how the results of such investigations are communicated to the requesting clinicians. The current process in the trust dictates that it is the responsibility of the Clinician requesting the investigation to 1 _ Detail the clinical picture on the request card, 2 Review the results and 3 Coordinate the care pathway depending on the information. very sorry
It is clear that channels of communication are needed to ensure that this system is effective_ The review confirmed that Salford Royal NHS Trust has the following protocols in place; Radiology Rapid Notification of Unsuspected Pathology (NUP) Suggestive of a Diagnosis of Cancer Policy Unique ID: TWCRO1(15) Standard Operating Policy: Alerting Clinicians to Unexpected Urgent or Life Threatening Findings on imaging In order to ensure that all members of the consultant body have knowledge of these protocols and their contents, have been disseminated by email and have been discussed at the Orthopaedic clinical governance meeting on the 29th March 2017 . hope that this response provides assurance to yourself and Mr Arthur's family that the Orthopaedic and Radiology department at Salford Royal have worked collaboratively to ensure that results following radiological investigation are communicated and reviewed in a timely manner to the medical teams coordinating patient's care in order to support the appropriate treatment plan. hope the Action Plan provides you with the assurance that the Trust takes patient safety issues seriously and is taking appropriate action to mitigate any future preventable deaths:
It is clear that channels of communication are needed to ensure that this system is effective_ The review confirmed that Salford Royal NHS Trust has the following protocols in place; Radiology Rapid Notification of Unsuspected Pathology (NUP) Suggestive of a Diagnosis of Cancer Policy Unique ID: TWCRO1(15) Standard Operating Policy: Alerting Clinicians to Unexpected Urgent or Life Threatening Findings on imaging In order to ensure that all members of the consultant body have knowledge of these protocols and their contents, have been disseminated by email and have been discussed at the Orthopaedic clinical governance meeting on the 29th March 2017 . hope that this response provides assurance to yourself and Mr Arthur's family that the Orthopaedic and Radiology department at Salford Royal have worked collaboratively to ensure that results following radiological investigation are communicated and reviewed in a timely manner to the medical teams coordinating patient's care in order to support the appropriate treatment plan. hope the Action Plan provides you with the assurance that the Trust takes patient safety issues seriously and is taking appropriate action to mitigate any future preventable deaths:
Action Should Be Taken
In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have power to take such action:
Report Sections
Investigation and Inquest
On the 10th October 2016 I commenced an investigation into the death of Gordon Arthur born on the 3rd September 1941. The investigation concluded at the end of the Inquest on the 25th January 2017. The Medical Cause of Death was: Ia Left Ventricular Hypertrophy due to Aortic Stenosis and Bronchopneumonia II Right Total Replacement The conclusion at the Inquest was that Gordon Arthur died as a consequence of a combination of naturally occurring disease and recognised complication of elective surgical treatment CIRCUMSTANCES OF THE DEATH On the 18th August 2016 Mr Arthur, who suffered from Left Ventricular Hypertrophy and Aortic Stenosis, underwent a Right Total Hip Replacement at Trafford General Hospital, Trafford and was discharged on the 21st August 2016. On the 31st August 2016 he was treated with antibiotic therapy for a suspected infection at the site of the surgery: On the September 2016 he suffered a cardiac arrest and was admitted to Salford Royal Hospital , Salford: He was resuscitated and underwent surgery to wash out the surgical site in order to treat the infection: Following this he had further surgery to wash out the site and close the wound on the 1th September 2016. He remained stable until his condition suddenly deteriorated on the Sth October 2016 and he died,Prior to Hip 6th the the surgery he had been active and mobile; but due to the surgery and subsequent treatment; his mobility significantly deteriorated: CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken; In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows: During the inquest evidence was heard that: The Consultant in charge of Mr Arthur's hip operation, and who carried out the surgery, was who is based at Salford Royal NHS Foundation Trust; Following Mr Arthur's discharge from Trafford General Hospital on the August he presented to the Accident and Emergency Department at Salford Royal Hospital on the 25t August as the surgical wound had started to ooze, which can be sign of infection: At that time an ultrasound scan of his hip was requested and the wound was redressed. confirmed the scan should have been done urgently, however it was not carried out until the 1st September
iii. Mr Arthur re-attended the Accident and Emergency department on the following with continued oozing from the surgical wound. The wound was redressed again and he was discharged. iv was not made aware of Mr Arthur's attendance at the Accident and Emergency Department on either the 25th or the 26t August until the 31s August; when he immediately requested that antibiotic therapy be prescribed, which Mr Arthur started taking that night; Had he been made aware of Mr Arthur's condition he would have admitted him on the 25h August for further investigation and treatment The ultrasound scan took place on the 1* September which revealed collection at the surgical site, again indicative of infection The radiologists reported the scan but this was never reviewed and was not made aware of the results;
vi. On the 6th September Mr Arthur was attending his GP for problem with his shoulder when he suffered a cardiac arrest; Fortunately Doctors were on hand to resuscitate him and he was taken to the Salford Royal Hospital where investigations revealed infection at the surgical site: He underwent surgery to wash out his hip that day: He was actively treated for that infection, which at the time of the post mortem examination had resolved 21st`
vii. From the evidence given the in the treatment of the infection at the site of the hip surgery was not, on the balance of probabilitiescausative or contributory to his death: During the evidence confirmed that there is no policy in place at the Trust detailing procedures for the request of investigations, such as scans or X-rays, nor is there policy relating to the notification of the results of such investigations to the Consultant in charge of the patient's care: I have concerns with regard to the following: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient's care could lead to patients not given the treatment require, which could result in a future death; therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to Consultant in charge of the patients care in order to prevent a future death; ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; 30th March 2017. 1, the coroner, may extend period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner ad to the following Interested Persons: Mr Arthur's wife on behalf of the family I am also under a duty to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest; You may make representations to me; the coroner, at the time of your response, about release or the publication of your response by the Chief Coroner_ delay being they the the the the
Dated Signed 2"d February 2017 Rachael C Griffin
iii. Mr Arthur re-attended the Accident and Emergency department on the following with continued oozing from the surgical wound. The wound was redressed again and he was discharged. iv was not made aware of Mr Arthur's attendance at the Accident and Emergency Department on either the 25th or the 26t August until the 31s August; when he immediately requested that antibiotic therapy be prescribed, which Mr Arthur started taking that night; Had he been made aware of Mr Arthur's condition he would have admitted him on the 25h August for further investigation and treatment The ultrasound scan took place on the 1* September which revealed collection at the surgical site, again indicative of infection The radiologists reported the scan but this was never reviewed and was not made aware of the results;
vi. On the 6th September Mr Arthur was attending his GP for problem with his shoulder when he suffered a cardiac arrest; Fortunately Doctors were on hand to resuscitate him and he was taken to the Salford Royal Hospital where investigations revealed infection at the surgical site: He underwent surgery to wash out his hip that day: He was actively treated for that infection, which at the time of the post mortem examination had resolved 21st`
vii. From the evidence given the in the treatment of the infection at the site of the hip surgery was not, on the balance of probabilitiescausative or contributory to his death: During the evidence confirmed that there is no policy in place at the Trust detailing procedures for the request of investigations, such as scans or X-rays, nor is there policy relating to the notification of the results of such investigations to the Consultant in charge of the patient's care: I have concerns with regard to the following: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient's care could lead to patients not given the treatment require, which could result in a future death; therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to Consultant in charge of the patients care in order to prevent a future death; ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; 30th March 2017. 1, the coroner, may extend period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner ad to the following Interested Persons: Mr Arthur's wife on behalf of the family I am also under a duty to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest; You may make representations to me; the coroner, at the time of your response, about release or the publication of your response by the Chief Coroner_ delay being they the the the the
Dated Signed 2"d February 2017 Rachael C Griffin
Circumstances of the Death
On the 18th August 2016 Mr Arthur, who suffered from Left Ventricular Hypertrophy and Aortic Stenosis, underwent a Right Total Hip Replacement at Trafford General Hospital, Trafford and was discharged on the 21st August 2016. On the 31st August 2016 he was treated with antibiotic therapy for a suspected infection at the site of the surgery: On the September 2016 he suffered a cardiac arrest and was admitted to Salford Royal Hospital , Salford: He was resuscitated and underwent surgery to wash out the surgical site in order to treat the infection: Following this he had further surgery to wash out the site and close the wound on the 1th September 2016. He remained stable until his condition suddenly deteriorated on the Sth October 2016 and he died,Prior to Hip 6th the the surgery he had been active and mobile; but due to the surgery and subsequent treatment; his mobility significantly deteriorated:
Inquest Conclusion
During the inquest evidence was heard that: The Consultant in charge of Mr Arthur's hip operation, and who carried out the surgery, was who is based at Salford Royal NHS Foundation Trust; Following Mr Arthur's discharge from Trafford General Hospital on the August he presented to the Accident and Emergency Department at Salford Royal Hospital on the 25t August as the surgical wound had started to ooze, which can be sign of infection: At that time an ultrasound scan of his hip was requested and the wound was redressed. confirmed the scan should have been done urgently, however it was not carried out until the 1st September
iii. Mr Arthur re-attended the Accident and Emergency department on the following with continued oozing from the surgical wound. The wound was redressed again and he was discharged. iv was not made aware of Mr Arthur's attendance at the Accident and Emergency Department on either the 25th or the 26t August until the 31s August; when he immediately requested that antibiotic therapy be prescribed, which Mr Arthur started taking that night; Had he been made aware of Mr Arthur's condition he would have admitted him on the 25h August for further investigation and treatment The ultrasound scan took place on the 1* September which revealed collection at the surgical site, again indicative of infection The radiologists reported the scan but this was never reviewed and was not made aware of the results;
vi. On the 6th September Mr Arthur was attending his GP for problem with his shoulder when he suffered a cardiac arrest; Fortunately Doctors were on hand to resuscitate him and he was taken to the Salford Royal Hospital where investigations revealed infection at the surgical site: He underwent surgery to wash out his hip that day: He was actively treated for that infection, which at the time of the post mortem examination had resolved 21st`
vii. From the evidence given the in the treatment of the infection at the site of the hip surgery was not, on the balance of probabilitiescausative or contributory to his death: During the evidence confirmed that there is no policy in place at the Trust detailing procedures for the request of investigations, such as scans or X-rays, nor is there policy relating to the notification of the results of such investigations to the Consultant in charge of the patient's care: I have concerns with regard to the following: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient's care could lead to patients not given the treatment require, which could result in a future death; therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to Consultant in charge of the patients care in order to prevent a future death; ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; 30th March 2017. 1, the coroner, may extend period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner ad to the following Interested Persons: Mr Arthur's wife on behalf of the family I am also under a duty to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest; You may make representations to me; the coroner, at the time of your response, about release or the publication of your response by the Chief Coroner_ delay being they the the the the
Dated Signed 2"d February 2017 Rachael C Griffin
iii. Mr Arthur re-attended the Accident and Emergency department on the following with continued oozing from the surgical wound. The wound was redressed again and he was discharged. iv was not made aware of Mr Arthur's attendance at the Accident and Emergency Department on either the 25th or the 26t August until the 31s August; when he immediately requested that antibiotic therapy be prescribed, which Mr Arthur started taking that night; Had he been made aware of Mr Arthur's condition he would have admitted him on the 25h August for further investigation and treatment The ultrasound scan took place on the 1* September which revealed collection at the surgical site, again indicative of infection The radiologists reported the scan but this was never reviewed and was not made aware of the results;
vi. On the 6th September Mr Arthur was attending his GP for problem with his shoulder when he suffered a cardiac arrest; Fortunately Doctors were on hand to resuscitate him and he was taken to the Salford Royal Hospital where investigations revealed infection at the surgical site: He underwent surgery to wash out his hip that day: He was actively treated for that infection, which at the time of the post mortem examination had resolved 21st`
vii. From the evidence given the in the treatment of the infection at the site of the hip surgery was not, on the balance of probabilitiescausative or contributory to his death: During the evidence confirmed that there is no policy in place at the Trust detailing procedures for the request of investigations, such as scans or X-rays, nor is there policy relating to the notification of the results of such investigations to the Consultant in charge of the patient's care: I have concerns with regard to the following: The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient's care could lead to patients not given the treatment require, which could result in a future death; therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to Consultant in charge of the patients care in order to prevent a future death; ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; 30th March 2017. 1, the coroner, may extend period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner ad to the following Interested Persons: Mr Arthur's wife on behalf of the family I am also under a duty to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest; You may make representations to me; the coroner, at the time of your response, about release or the publication of your response by the Chief Coroner_ delay being they the the the the
Dated Signed 2"d February 2017 Rachael C Griffin
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Pre-1996 Transfusion Testing
Infected Blood Inquiry
Delayed patient infection risk notification
Incomplete GP Patient Data Transfer
Eligibility Conditions for Infected Persons
Infected Blood Inquiry
Delayed patient infection risk notification
HCV Testing for Pre-1991 Transfusion Recipients
Penrose Inquiry
Delayed patient infection risk notification
CDI senior assessment and treatment
Vale of Leven Inquiry
Delayed patient infection risk notification
Isolation for infectious diarrhoea
Vale of Leven Inquiry
Delayed patient infection risk notification
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.