David Martin
PFD Report
All Responded
Ref: 2024-0536
All 1 response received
· Deadline: 3 Dec 2024
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
3 Dec 2024
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 inquest heard evidence that the locum SHO involved in the care of Mr Martin was 9 days into a 3-4 month period of cover. She had not received any cardiology induction and was unaware of the Trust DAPT policy regarding PCI patients. It was accepted that while it was a challenge to ensure locums who covered 1-2 shifts had a thorough induction, where one was being asked to work in the service for an extended period of time, it was necessary that there was a proper induction process. The inquest heard changes have already been made in this regard.
2) There were multiple opportunities where the fact Mr Martin was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues.
2) There were multiple opportunities where the fact Mr Martin was receiving Aspirin only was not recognised. This included the completion of a WHO checklist intended to identify issues of this nature. Of greater concern is that a Deputy Sister who completed the cardiac cath lab pack did recognise the oversight but this was still not acted upon by medical colleagues.
Responses
The Trust has reviewed, agreed, and approved revised wording for the PCI pack regarding Dual Anti-Platelet Therapy, with updated forms sent for publishing and Local Safety Standards for Invasive Procedures (LocSSiP) to be updated. It is also developing a training package for nursing teams and amending nursing, junior doctor, and locum induction programmes to include catheter lab pack and preparation, expected by 31 December 2024.
AI summary
View full response
Dear Mr Cox Re: Death of David Charles Martin - R28 PFD Report & letter I write in response to the Regulation 28 Report to Prevent Future Deaths, dated and received on the 10th of October 2024, issued as a result of the inquest into the death of Mr Martin which took place on 8th October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Martin for their loss. During the course of the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Could changes be made to the cardiac catheter lab pack and the WHO checklist that would make the process more robust and prevent similar incidents in the future.
• Could changes be made to the induction programme for locum doctors.
Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Can changes be made to the cardiac catheter lab pack and WHO checklist: The wording in the PCI pack has been reviewed in order to make the provision of Dual Anti- Platelet Therapy clearer to both the medical and nursing team. The proposed revised wording was first agreed by the Cardiology team and was then sent to the Safer Surgery Group (SSG) for ratification and approval. SSG approved the changes at a meeting on 15 November 2024. The revised wording was also submitted to the Forms Review Group on 13 November 2024 and they were ratified and agreed by this group on 18 November 2024. The updated forms have been sent to the publishers and are currently awaiting return. The Local Safety Standards for Invasive Procedure (LocSSiP) will be updated and will be available on the intranet for staff. A copy of the updated paperwork can be provided if required upon return from the publishers. Can changes be made to the Induction Programme for locums: The Trust is developing a training package for our Roskear Nursing Team and we are in the process of amending our nursing, junior doctors and locum induction programmes to include catheter lab pack and preparation. This is underway and is expected to be completed by 31 December 2024. To summarise the above, the Trust have taken the following actions
1. Reviewed and amended the wording in the PCI pack regarding provision of Dual Anti- Platelet Therapy.
2. Sent the revised wording to Forms Review Group and Safer Surgery Group for ratification and approval.
3. Sent updated forms to the publishers.
4. Update the Local Safety Standards for Invasive Procedures (LocSSip).
5. Develop a training package for Roskear Nursing teams – due for completion by 31 December 2024.
6. Add catheter lab packs and preparation to Nursing induction – due for completion by 31 December 2024.
7. Add catheter lab packs and preparation to Junior Doctor and Locum Induction – due for completion by 31 December 2024. I hope that this letter provides both you and Mr Martin’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
• Could changes be made to the cardiac catheter lab pack and the WHO checklist that would make the process more robust and prevent similar incidents in the future.
• Could changes be made to the induction programme for locum doctors.
Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Can changes be made to the cardiac catheter lab pack and WHO checklist: The wording in the PCI pack has been reviewed in order to make the provision of Dual Anti- Platelet Therapy clearer to both the medical and nursing team. The proposed revised wording was first agreed by the Cardiology team and was then sent to the Safer Surgery Group (SSG) for ratification and approval. SSG approved the changes at a meeting on 15 November 2024. The revised wording was also submitted to the Forms Review Group on 13 November 2024 and they were ratified and agreed by this group on 18 November 2024. The updated forms have been sent to the publishers and are currently awaiting return. The Local Safety Standards for Invasive Procedure (LocSSiP) will be updated and will be available on the intranet for staff. A copy of the updated paperwork can be provided if required upon return from the publishers. Can changes be made to the Induction Programme for locums: The Trust is developing a training package for our Roskear Nursing Team and we are in the process of amending our nursing, junior doctors and locum induction programmes to include catheter lab pack and preparation. This is underway and is expected to be completed by 31 December 2024. To summarise the above, the Trust have taken the following actions
1. Reviewed and amended the wording in the PCI pack regarding provision of Dual Anti- Platelet Therapy.
2. Sent the revised wording to Forms Review Group and Safer Surgery Group for ratification and approval.
3. Sent updated forms to the publishers.
4. Update the Local Safety Standards for Invasive Procedures (LocSSip).
5. Develop a training package for Roskear Nursing teams – due for completion by 31 December 2024.
6. Add catheter lab packs and preparation to Nursing induction – due for completion by 31 December 2024.
7. Add catheter lab packs and preparation to Junior Doctor and Locum Induction – due for completion by 31 December 2024. I hope that this letter provides both you and Mr Martin’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Action Should Be Taken
The inquest heard from Matron as well as Drs and . All felt changes could be made to the cardiac cath lab pack and the WHO checklist that would make the process more robust and prevent similar instances in the future.
Report Sections
Investigation and Inquest
On 8/10/24, I concluded the inquest into the death of David Charles Martin who died in RCHT on 17/9/22.
I recorded the cause of death as: 1a) Left ventricular cardiac failure (post-stenting) 1b) Coronary artery thrombosis 1c) Coronary artery disease II) Atrial fibrillation; Chronic kidney disease
I recorded a conclusion of Natural Causes.
I recorded the cause of death as: 1a) Left ventricular cardiac failure (post-stenting) 1b) Coronary artery thrombosis 1c) Coronary artery disease II) Atrial fibrillation; Chronic kidney disease
I recorded a conclusion of Natural Causes.
Circumstances of the Death
Mr Martin was an 83-year-old man with a history of progressive heart failure. He was admitted into Royal Cornwall Hospital on 30/8/22 with deteriorating symptoms. He had a diagnostic angiogram on 5/9/22 before a decision was made at a cardiology MDT on 12/9/22 that he was not for surgical intervention and was offered stenting (PCI) instead. The procedure took place on 16/9/22. It was Trust policy that patients undergoing PCI should have dual anti-platelet therapy (DAPT.) In error, Mr Martin was prescribed Aspirin only and the oversight was only identified post-operatively when Mr Martin was immediately given a loading dose of a second anti-platelet therapy. Mr Martin collapsed later that afternoon. He was resuscitated but then deteriorated and died in the hospital on 17/9/22. It is unlikely the cause of Mr Martin's collapse was a clot in an inserted stent and thus the oversight in the provision of a second anti-platelet therapy was not causative of Mr Martin's demise. Information Classification: CONTROLLED
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Strengthening identification of healthcare support workers and nurses
Mid Staffs Inquiry
Unqualified Staff Deployment
Strengthening identification of healthcare support workers and nurses
Mid Staffs Inquiry
Unqualified Staff Deployment
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.