Carl Wright
PFD Report
All Responded
Ref: 2022-0324
All 1 response received
· Deadline: 13 Dec 2022
Response Status
Responses
1 of 1
56-Day Deadline
13 Dec 2022
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
(1) The majority of medical care, including the identification and assessment of deteriorating patients, was done by inexperienced junior doctors with no easy access to input from more experienced doctors; and
(2) There was an established culture and practice of most blood tests results not being reviewed in a timely manner. Other areas of concern existed regarding other issues but plans were in place to address these areas and so I did not have ongoing concerns of a risk of future deaths.
(2) There was an established culture and practice of most blood tests results not being reviewed in a timely manner. Other areas of concern existed regarding other issues but plans were in place to address these areas and so I did not have ongoing concerns of a risk of future deaths.
Responses
The Trust has implemented immediate actions including requiring a Consultant review for all patients transferred to Linden Lodge, developing a new SOP for medical speciality referrals, and establishing a daily review of all blood test results as part of the weekly ward round.
AI summary
View full response
Dear Mr Clow
Inquest: Carl Wright - Prevention of Future Death Report [PFDR] Response
Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Wright. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Neurology Service, Surgical Division and more broadly in regard to medical management at the City Campus of NUH.
The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight. Sub-Committees of our Boards will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.
Inquest: Carl Wright - Prevention of Future Death Report [PFDR] Response
Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Wright. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Neurology Service, Surgical Division and more broadly in regard to medical management at the City Campus of NUH.
The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight. Sub-Committees of our Boards will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.
Report Sections
Investigation and Inquest
An investigation was opened touching on the death of Carl Wright on 3 November 2021.
The investigation concluded at the end of the inquest on 28 September 2022. The conclusion of the inquest was the short form conclusion that Carl Wright’s death was from natural causes, with a supporting narrative as follows:-
“There was sufficient information available for a suitably experienced doctor to ascertain that Mr Wright was suffering from an infection on or before 22 October 2021. This would have prompted investigations which would have identified the abscess earlier than 26 October 2021. This would, in turn, have improved Mr Wright’s chances of survival. It is not possible to say, on the available evidence, whether or not Mr Wright would have survived had this taken place.”
The investigation concluded at the end of the inquest on 28 September 2022. The conclusion of the inquest was the short form conclusion that Carl Wright’s death was from natural causes, with a supporting narrative as follows:-
“There was sufficient information available for a suitably experienced doctor to ascertain that Mr Wright was suffering from an infection on or before 22 October 2021. This would have prompted investigations which would have identified the abscess earlier than 26 October 2021. This would, in turn, have improved Mr Wright’s chances of survival. It is not possible to say, on the available evidence, whether or not Mr Wright would have survived had this taken place.”
Circumstances of the Death
On 4 June 2021 Mr Carl Wright underwent complex cardiac surgery against a background of previous stroke and other serious health conditions including diabetes mellitus, cerebrovascular disease and peripheral vascular disease. He suffered significant setbacks during and after the surgery and remained on the intensive care unit for approximately eight weeks.
Mr Wright was transferred to a rehabilitation unit. The rehabilitation unit did not undertake the usual assessments and decision making prior to Mr Wright’s admission. Mr Wright was not sufficiently well to be safely cared for on the rehabilitation unit and his postural hypotension rendered him unsuitable for that form of inpatient rehabilitation. The unit itself was not well suited to Mr Wright’s particular needs.
Whilst on the rehabilitation unit Mr Wright’s medical condition was not reviewed very frequently. Blood samples taken on 14 October 2021 showed evidence of an infection. No doctor reviewed these results at the time and no further action was taken in response.
On 20 October 2021 Mr Wright began to demonstrate symptoms consistent with, but not clearly typical of, an infection. The medical care available to Mr Wright on 20, 21 and 22 October 2021 was limited to input from an inexperienced junior doctor. A consultant could have been contacted by the junior doctor on the 20, 21 or 22 October 2021. The junior doctor did not contact a consultant for advice.
Mr Wright’s symptoms during this period were caused by an abdominal abscess. Routine investigations which would have led to an earlier identification of the abscess were not undertaken. At no time during this period did the junior doctor responsible for Mr Wright’s care make any entries in the medical running records. This made it more difficult for other doctors to form a view about Mr Wright’s medical situation.
Mr Wright’s medical condition was not reviewed as regularly as his condition indicated. The above factors delayed the diagnosis of Mr Wright’s infection and abscess. Mr Wright then went on to develop sepsis in response to the infection in the following days.
By the time Mr Wright’s abscess had been identified, on 26 October 2021, he was too unwell, and the abscess collection was too irregular, for surgery or interventional radiology to be attempted. He was provided with appropriate care to maximise his comfort and then died on 29 October 2021.
Mr Wright was transferred to a rehabilitation unit. The rehabilitation unit did not undertake the usual assessments and decision making prior to Mr Wright’s admission. Mr Wright was not sufficiently well to be safely cared for on the rehabilitation unit and his postural hypotension rendered him unsuitable for that form of inpatient rehabilitation. The unit itself was not well suited to Mr Wright’s particular needs.
Whilst on the rehabilitation unit Mr Wright’s medical condition was not reviewed very frequently. Blood samples taken on 14 October 2021 showed evidence of an infection. No doctor reviewed these results at the time and no further action was taken in response.
On 20 October 2021 Mr Wright began to demonstrate symptoms consistent with, but not clearly typical of, an infection. The medical care available to Mr Wright on 20, 21 and 22 October 2021 was limited to input from an inexperienced junior doctor. A consultant could have been contacted by the junior doctor on the 20, 21 or 22 October 2021. The junior doctor did not contact a consultant for advice.
Mr Wright’s symptoms during this period were caused by an abdominal abscess. Routine investigations which would have led to an earlier identification of the abscess were not undertaken. At no time during this period did the junior doctor responsible for Mr Wright’s care make any entries in the medical running records. This made it more difficult for other doctors to form a view about Mr Wright’s medical situation.
Mr Wright’s medical condition was not reviewed as regularly as his condition indicated. The above factors delayed the diagnosis of Mr Wright’s infection and abscess. Mr Wright then went on to develop sepsis in response to the infection in the following days.
By the time Mr Wright’s abscess had been identified, on 26 October 2021, he was too unwell, and the abscess collection was too irregular, for surgery or interventional radiology to be attempted. He was provided with appropriate care to maximise his comfort and then died on 29 October 2021.
Copies Sent To
set out above
Inquest Conclusion
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“There was sufficient information available for a suitably experienced doctor to ascertain that Mr Wright was suffering from an infection on or before 22 October 2021. This would have prompted investigations which would have identified the abscess earlier than 26 October 2021. This would, in turn, have improved Mr Wright’s chances of survival. It is not possible to say, on the available evidence, whether or not Mr Wright would have survived had this taken place.”
“There was sufficient information available for a suitably experienced doctor to ascertain that Mr Wright was suffering from an infection on or before 22 October 2021. This would have prompted investigations which would have identified the abscess earlier than 26 October 2021. This would, in turn, have improved Mr Wright’s chances of survival. It is not possible to say, on the available evidence, whether or not Mr Wright would have survived had this taken place.”
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Public inquiry recommendations addressing similar themes
Hepatologist Oversight and Fibroscan Access
Infected Blood Inquiry
Delayed Recognition of Deterioration
Annual GP Appointment for Co-morbidities
Infected Blood Inquiry
Delayed Recognition of Deterioration
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.