Joan Knight
PFD Report
All Responded
Ref: 2024-0566
All 1 response received
· Deadline: 17 Dec 2024
Coroner's Concerns (AI summary)
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
View full coroner's concerns
1. The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths.
Responses
Action Taken
The trust has disabled multiple methodology coding fields in its Dendrite software, requested specialties use Learning from Deaths Team recommended coding scores, and identified specialties using Dendrite software. It plans to pilot a new M&M recording platform, roll it out across the Trust, publish updated M&M standards, and introduce a Trust Mortality Committee. (AI summary)
The trust has disabled multiple methodology coding fields in its Dendrite software, requested specialties use Learning from Deaths Team recommended coding scores, and identified specialties using Dendrite software. It plans to pilot a new M&M recording platform, roll it out across the Trust, publish updated M&M standards, and introduce a Trust Mortality Committee. (AI summary)
View full response
Dear Mrs Hunt
Inquest touching the death of Mrs Joan Knight Response to Regulation 28 Report to prevent future deaths
I am writing in response to the Regulation 28 notice issued following the conclusion of the inquest on 21 October 2024, into the death of Mrs Joan Knight at Queen Elizabeth Hospital Birmingham (part of University Hospital Birmingham NHS Foundation Trust). I extend my sincere apologies to Mrs Knight’s family.
I note your narrative conclusion was that Mrs Knight died from the consequences of a recognised complication following treatment for severe coronary artery stenosis.
I further note your concern regarding the risk of future deaths, which has been addressed below. The focus of the actions has been at the Queen Elizabeth Hospital Birmingham (QEHB) but the learning identified in this response has been shared with each of the responsible Hospital Medical Directors and Directors of Nursing covering QEHB, Birmingham Heartlands Hospital and Good Hope Hospital respectively for implementation.
We have carefully considered the concerns raised within your report to prevent future deaths, relating to the conduct and recording of mortality reviews.
Concern: The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being concluded correctly and that there could be inadequate learning from cases raising a risk of future deaths.
As part of our disclosure to you for the inquest we provided a copy of the mortality review completed by the speciality responsible for Mrs Knight at their M&M meeting.
Following review and discussion with the speciality we have learnt that they are one of only two specialties still using legacy IT software (Dendrite) for capturing mortality reviews. The software allowed the input of multiple methodology coding scores for recording; Quality of Care, Preventability and Categorisation/Nature of Death, which could potentially appear contradictory.
We have taken the following immediate steps to rectify this concern and reduce the likelihood of reoccurrence:
1. We have requested that the speciality use the three methodology coding scores recommended by the Learning from Deaths Team in line with the rest of the Trust and we have disabled the use of all other methodology coding fields on the software.
2. We have identified the specialities within the Trust who are currently using the Dendrite software for capturing mortality review. (Cardiology plus one other speciality, both on the Birmingham Heartlands Hospital site)
3. A new Mortality & Morbidity recording platform has been developed and is to be piloted prioritising the two identified specialities using the Dendrite software.
In addition, the following planned steps are due to be completed within the next 12 months:
1. A New Mortality & Morbidity recording platform is to be rolled out across the remainder of the Trust once piloted.
2. Updated Mortality & Morbidity standards are to be published and readily available on the Trust intranet.
3. The introduction of a Trust Mortality Committee, commencing in December 2024.
I would like to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously, which I hope is demonstrated in the steps we have taken in reviewing and strengthening our systems, processes and training provision to our teams.
Inquest touching the death of Mrs Joan Knight Response to Regulation 28 Report to prevent future deaths
I am writing in response to the Regulation 28 notice issued following the conclusion of the inquest on 21 October 2024, into the death of Mrs Joan Knight at Queen Elizabeth Hospital Birmingham (part of University Hospital Birmingham NHS Foundation Trust). I extend my sincere apologies to Mrs Knight’s family.
I note your narrative conclusion was that Mrs Knight died from the consequences of a recognised complication following treatment for severe coronary artery stenosis.
I further note your concern regarding the risk of future deaths, which has been addressed below. The focus of the actions has been at the Queen Elizabeth Hospital Birmingham (QEHB) but the learning identified in this response has been shared with each of the responsible Hospital Medical Directors and Directors of Nursing covering QEHB, Birmingham Heartlands Hospital and Good Hope Hospital respectively for implementation.
We have carefully considered the concerns raised within your report to prevent future deaths, relating to the conduct and recording of mortality reviews.
Concern: The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being concluded correctly and that there could be inadequate learning from cases raising a risk of future deaths.
As part of our disclosure to you for the inquest we provided a copy of the mortality review completed by the speciality responsible for Mrs Knight at their M&M meeting.
Following review and discussion with the speciality we have learnt that they are one of only two specialties still using legacy IT software (Dendrite) for capturing mortality reviews. The software allowed the input of multiple methodology coding scores for recording; Quality of Care, Preventability and Categorisation/Nature of Death, which could potentially appear contradictory.
We have taken the following immediate steps to rectify this concern and reduce the likelihood of reoccurrence:
1. We have requested that the speciality use the three methodology coding scores recommended by the Learning from Deaths Team in line with the rest of the Trust and we have disabled the use of all other methodology coding fields on the software.
2. We have identified the specialities within the Trust who are currently using the Dendrite software for capturing mortality review. (Cardiology plus one other speciality, both on the Birmingham Heartlands Hospital site)
3. A new Mortality & Morbidity recording platform has been developed and is to be piloted prioritising the two identified specialities using the Dendrite software.
In addition, the following planned steps are due to be completed within the next 12 months:
1. A New Mortality & Morbidity recording platform is to be rolled out across the remainder of the Trust once piloted.
2. Updated Mortality & Morbidity standards are to be published and readily available on the Trust intranet.
3. The introduction of a Trust Mortality Committee, commencing in December 2024.
I would like to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously, which I hope is demonstrated in the steps we have taken in reviewing and strengthening our systems, processes and training provision to our teams.
Sent To
- University Hospitals Birmingham NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
17 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
Report Sections
Investigation and Inquest
On 11 June 2024 I commenced an investigation into the death of Joan Margaret KNIGHT. The investigation concluded at the end of the Inquest . The conclusion of the inquest was; Died from the consequences of a recognised complication following treatment for severe coronary artery stenosis
Circumstances of the Death
Mrs Knight suffered an acute inferior wall myocardial infarction on 16/05/24 and had treatment by way of angioplasty to her right coronary artery with a stent being fitted. The procedure was complicated as she was found to have significant calcium build up in the coronary artery. It was also noted that the left anterior descending artery had severe narrowing. Initially after the procedure she was pain free; however she began to experience further chest pain on 18/05/24 which was treated with medication. The chest pain recurred on 20/05/24 and a further procedure to insert a stent into the left anterior descending artery was undertaken on 21/05/24. During the procedure access was difficult and significant calcification was noted. During ballooning the coronary artery ruptured and was successfully treated with a stent. Whilst initially stable after the procedure her condition deteriorated, and she presented with an unrecordable blood pressure. A bedside echocardiogram confirmed a collection of blood around the heart and an emergency pericardial aspiration was undertaken and she was taken back to the cardiac catheter lab where a covered stent was fitted to try to treat the bleeding at the site of the previous perforation. The bleeding was difficult to control and arrangements were made to transfer her to the Queen Elizabeth Hospital where a CT scan confirmed bleeding in the abdomen. She was taken to theatre where no site for bleeding was found in the abdomen; however a small perforation in the right ventricle was identified and repaired which was likely caused when the emergency aspiration procedure was undertaken. Sadly, she developed multi organ failure in the post operative period and passed away on 25/05/24. Based on information from the Deceased’s treating clinicians, the medical cause of death was determined to be: 1a Multiple organ failure 1b intrabdominal bleeding from chest compressions and ventricular bleeding secondary to emergency pericardial aspiration (operated) 1c cardiac tamponade 1d treatment for severe stenosis of the left anterior descending coronary artery leading to perforation and bleeding
II Myocardial infarction (treated)
II Myocardial infarction (treated)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.