Nancy Rogers
PFD Report
All Responded
Ref: 2024-0366
All 1 response received
· Deadline: 3 Sep 2024
Coroner's Concerns (AI summary)
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection presentations.
View full coroner's concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) At the inquest into Shirley Potter's death the hospital report indicated no learning was required as her presentation was not typical. The circumstances in both these cases are remarkably similar in that both ladies attended the emergency department at Furness General and were allowed home only to die within a day of the same cause and as far as the attending clinician at today's hearing knew no learning or teaching has taken place since Nancy's death.
(2) As a coroner I am not permitted to suggest what actions might be taken but feel it safe to mention NHS futures Aortic Dissection Toolkit and The Aortic Dissection Charitable Trust for further information. (3)
(2) As a coroner I am not permitted to suggest what actions might be taken but feel it safe to mention NHS futures Aortic Dissection Toolkit and The Aortic Dissection Charitable Trust for further information. (3)
Responses
Action Taken
University Hospitals of Morecambe Bay NHS Foundation Trust has displayed posters in the Emergency Department and triage areas, and they are drawing attention to a relevant video at staff meetings. Aortic dissection is now included in the new doctor induction, and a Standard Operating Procedure for the management of Aortic Dissection is being created. (AI summary)
University Hospitals of Morecambe Bay NHS Foundation Trust has displayed posters in the Emergency Department and triage areas, and they are drawing attention to a relevant video at staff meetings. Aortic dissection is now included in the new doctor induction, and a Standard Operating Procedure for the management of Aortic Dissection is being created. (AI summary)
View full response
Dear Dr Shaw, Regulation 28 Report to Prevent Further Deaths Thank you for your report dated 9 July 2024. am sorry that you have had cause to make report; but we have carefully considered the concerns raised and | can now advise as follows meeting was held between the Clinical Lead Emergency Medicine (FGH), the Clinical Lead Emergency Medicine (RLI) , the Clinical Lead Urgent Treatment Centre WGH and the Deputy Medical Director (Education, Research, Workforce and Innovation) to discuss the cases of Shirley Potter and Nancy Rogers and another case that we had noted in the jurisdiction of the Senior Coroner Lancashire and Blackburn with Darwen. The discussion at meeting centred on the best way to disseminate information regarding aortic dissection, in order to reduce the risk of this diagnosis being missed in the future. An action plan was written and since the meeting, the following actions have been put in place: Contact has been made with the Aortic Dissection Charitable Trust and consent has been obtained to use their data and logos in any materials, teaching or discussions_ An A4 poster has been created (copy attached) and is displayed in the Emergency Department (ED) clinical areas and triage, for quick reference The QR code links to a video on the Aortic Dissection Charitable Trust's website. The video on the Aortic Dissection Charitable Trust website is being drawn to the attention of senior and junior medical staff at ED meetings at both of the Trust's main hospitals, between July and the end of September. A list of the Bay Our the
relevant staff has been compiled and new starters will be added. A tracker is being maintained of the dates when the video was viewed: A similar arrangement is also in place for nursing staff who perform triage. Similar awareness raising is taking place at the Kendal Urgent Treatment Unit and the Same Day Emergency Care and Acute Medical Units. Aortic dissection is now included in the new doctor induction in August: A Standard Operating Procedure (SOP) for the management of Aortic Dissection is being created, to ensure a consistent approach to the management of aortic dissection throughout the Trust This will be uploaded to Trust Procedural Documents library, which can be accessed from any Trust computer: There is currently a SOP in the medical guidelines and there are also regional guidelines. These are being combined for clarity and it is anticipated that this will be completed within the next 4-6 weeks. An audit of the SOP has been included in the Audit Calendar: this information is helpful but if you should require anything further, including a copy of the Action Plan, please do not hesitate to contact me.
relevant staff has been compiled and new starters will be added. A tracker is being maintained of the dates when the video was viewed: A similar arrangement is also in place for nursing staff who perform triage. Similar awareness raising is taking place at the Kendal Urgent Treatment Unit and the Same Day Emergency Care and Acute Medical Units. Aortic dissection is now included in the new doctor induction in August: A Standard Operating Procedure (SOP) for the management of Aortic Dissection is being created, to ensure a consistent approach to the management of aortic dissection throughout the Trust This will be uploaded to Trust Procedural Documents library, which can be accessed from any Trust computer: There is currently a SOP in the medical guidelines and there are also regional guidelines. These are being combined for clarity and it is anticipated that this will be completed within the next 4-6 weeks. An audit of the SOP has been included in the Audit Calendar: this information is helpful but if you should require anything further, including a copy of the Action Plan, please do not hesitate to contact me.
Sent To
- University Hospitals Morecambe Bay Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
3 Sep 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 22 November 2023 I commenced an investigation into the death of Nancy ROGERS. The investigation concluded at the end of the inquest . The conclusion of the inquest on 9th July 2024 was Death from natural causes. The medical cause of death being 1a Bilateral Haemothorax 1b Ruptured Dissecting Aortic Aneurysm 1c II I also refer to an inquest opened on 10th August 2023 and concluded on 23/11/23 touching on the death on 12th February 2023 of , the medical cause of death being 1a Haemopericardium due to 1b Ruptured Dissecting Aortic Aneurysm 4 CIRCUMSTANCES OF THE DEATH
18/11/2023-Nancy collapsed outside on Storey Square, Barrow when she was walking with her sister into town. This occurred around 1300hrs. An ambulance was called and Nancy attended A&E. She had tests done however the results were not back and they are due to come back on Monday 20/11/2023. Hospital discharged Nancy back to her home address. They stated she possibly had fluid on her lung which would need a referral. On 19/11/2023 at around 0530hrs helped Nancy to the toilet; she left the bathroom to give Nancy some privacy and immediately heard her fall. went into the bathroom and Nancy was not breathing. CPR was started and the neighbour came over as she heard the shouting through the wall. No response to CPR from family attempts and paramedics arrived to continue. Nancy is in the process of selling her home to return to the Philippines and this has been causing her some stress.
18/11/2023-Nancy collapsed outside on Storey Square, Barrow when she was walking with her sister into town. This occurred around 1300hrs. An ambulance was called and Nancy attended A&E. She had tests done however the results were not back and they are due to come back on Monday 20/11/2023. Hospital discharged Nancy back to her home address. They stated she possibly had fluid on her lung which would need a referral. On 19/11/2023 at around 0530hrs helped Nancy to the toilet; she left the bathroom to give Nancy some privacy and immediately heard her fall. went into the bathroom and Nancy was not breathing. CPR was started and the neighbour came over as she heard the shouting through the wall. No response to CPR from family attempts and paramedics arrived to continue. Nancy is in the process of selling her home to return to the Philippines and this has been causing her some stress.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.