William Nichols
PFD Report
All Responded
Ref: 2023-0308
All 2 responses received
· Deadline: 2 Nov 2023
Coroner's Concerns (AI summary)
Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.
View full coroner's concerns
Despite the known catastrophic risks of deep patch infection following endarterectomy and the significance of a herald bleed:
(1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding).
(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding).
(3) Poor communication from the vascular ward when concerns were raised post-operatively, particularly the concern about bleeding in the wound discharge.
(4) Poor record keeping from the community team which meant that key clinical assessment information was not consistently recorded.
(1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding).
(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding).
(3) Poor communication from the vascular ward when concerns were raised post-operatively, particularly the concern about bleeding in the wound discharge.
(4) Poor record keeping from the community team which meant that key clinical assessment information was not consistently recorded.
Responses
Action Taken
Newcastle Upon Tyne Hospitals NHS Foundation Trust provides patients with a Femoral Endarterectomy Patient Information Leaflet pre-admission and post-discharge, including contact points. They have also implemented changes following a Serious Incident Investigation to ensure documented advice is provided to patients on discharge and that community teams have points of access for concerns or complications. (AI summary)
Newcastle Upon Tyne Hospitals NHS Foundation Trust provides patients with a Femoral Endarterectomy Patient Information Leaflet pre-admission and post-discharge, including contact points. They have also implemented changes following a Serious Incident Investigation to ensure documented advice is provided to patients on discharge and that community teams have points of access for concerns or complications. (AI summary)
View full response
Dear Doctor Patient Name NHS Number: Patient Address DoB: MRN: Your patient was admitted as an inpatient to Freeman Ward 08 on 02/10/2023 and was discharged home on 06/10/2023. Diagnosis _ Intermittent claudication right calf Clinical Details This patient was admitted electively for a right common femoral endarterectomy. This was completed successfully and the artery closed with a bovine patch. He made an uneventful recovery. Operations & Procedures Right common femoral endarterectomy - 2/10/23 Discharge Medication Clopidogrel 75 mg daily Atorvastatin 80 mg daily Information to Patient Mild wound discomfort is common following arterial surgery in the groi~. Ifthere is concern, you can contact the vascular team via Ward 8 for advice on 0191 213 7008. If at any point there is bleeding or a blood-stained discharge from the wound, you should seek urgent medical attention via your nearest Accident & Emergency Department.
Action Taken
Gateshead Health NHS Foundation Trust educated staff on risks following femoral endarterectomy and improved communication with Newcastle Trust, creating a professional information leaflet for district nurses outlining postoperative awareness, escalation and intervention. They enhanced their electronic record system to improve record keeping. (AI summary)
Gateshead Health NHS Foundation Trust educated staff on risks following femoral endarterectomy and improved communication with Newcastle Trust, creating a professional information leaflet for district nurses outlining postoperative awareness, escalation and intervention. They enhanced their electronic record system to improve record keeping. (AI summary)
View full response
Dear Ma'am,
Inquest into the death of William Nichols
We write to formally respond to your Prevention of Future Deaths (PFD) Report, dated 18 August 2023, following the sad death of Mr Nichols. As a Trust we have learnt from the circumstances of Mr Nichols' death and have taken action following his death to try and improve communication between ourselves and the Newcastle upon Tyne Hospitals, NHS Foundation Trust (Newcastle Trust) and to educate staff on the risks following a femoral endarterectomy.
We have reviewed the concerns identified in your PFD report and note that points 2 and 3 are not applicable to our Trust. We shall therefore respond to points 1 and 4 in turn below.
Concern 1: Inconsistency in the understanding between the hospital and community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection or bleeding.)
It is the Trust's position that we have already addressed this concern (and had done so by the time of the inquest hearing) and therefore it is unclear if this concern is directed at us, but in the event that it is, we would respond as follows.
As heard at the inquest and in our subsequent submissions made by letter in July 2023, the Trust followed the correct procedure of contacting the ward at the Newcastle Trust, when the Community team noted the presence of fresh blood and spoke with a Specialist Vascular Nurse from the Newcastle Trust for advice, who in turn spoke with a medic from the Vascular Team. Following the inquest, the Trust liaised with the Newcastle Trust, to ensure that this remains the correct procedure for contacting their team and they have confirmed it does.
Gateshead Health NHS Foundation Trust Trust Headquarters Queen Elizabeth Hospital Sheriff Hill Gateshead NE9 6SX
-2-
Following the inquest and collaboration with the Newcastle Trust, the findings of the inquest have been shared with our District Nurses, to reiterate the process they already follow, including:
• Contacting the inpatient ward for advice (whether that be a ward within this Trust or another Trust);
• Where to locate contact information for the relevant ward; and
• A reminder of signs to look out for with patients who have undergone a femoral endarterectomy.
We have also been liaising with the Newcastle Trust and developed a professional information leaflet for District Nurses which outlines what they should be aware of in relation to this specific procedure in the post operative period and what requires escalation and intervention, We understand you have received this from Newcastle Trust. We have therefore done all we can as a Trust in relation to this concern.
Concern 4: Poor record keeping from the community team which mean that key clinical assessment information was not consistently recorded.
Having reviewed the evidence, we are unable to ascertain where this concern arises from, which makes it difficult to respond directly. However, we would be more than willing to address this further if more detail about the concern could be provided.
As a Trust, we pride ourselves on ensuring that record keeping is a priority. In Mr Nichols' case, key clinical information was recorded, with space to add to pre-populated drop-down boxes and concerns were appropriately raised with the Newcastle Trust, when fresh blood was identified in Mr Nichols' colostomy bag.
As referred to in the inquest, at the time of Mr Nichol's death, the Trust had only very recently moved to a fully electronic records system. This system is now fully embedded and since Mr Nichols' death, 4 years ago, numerous changes have been made to the electronic proformas to strengthen record keeping and capture accurate and key clinical information.
We hope that the above addresses your concerns, but please do revert back to us should you have any further comments or queries with which we can assist.
Inquest into the death of William Nichols
We write to formally respond to your Prevention of Future Deaths (PFD) Report, dated 18 August 2023, following the sad death of Mr Nichols. As a Trust we have learnt from the circumstances of Mr Nichols' death and have taken action following his death to try and improve communication between ourselves and the Newcastle upon Tyne Hospitals, NHS Foundation Trust (Newcastle Trust) and to educate staff on the risks following a femoral endarterectomy.
We have reviewed the concerns identified in your PFD report and note that points 2 and 3 are not applicable to our Trust. We shall therefore respond to points 1 and 4 in turn below.
Concern 1: Inconsistency in the understanding between the hospital and community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection or bleeding.)
It is the Trust's position that we have already addressed this concern (and had done so by the time of the inquest hearing) and therefore it is unclear if this concern is directed at us, but in the event that it is, we would respond as follows.
As heard at the inquest and in our subsequent submissions made by letter in July 2023, the Trust followed the correct procedure of contacting the ward at the Newcastle Trust, when the Community team noted the presence of fresh blood and spoke with a Specialist Vascular Nurse from the Newcastle Trust for advice, who in turn spoke with a medic from the Vascular Team. Following the inquest, the Trust liaised with the Newcastle Trust, to ensure that this remains the correct procedure for contacting their team and they have confirmed it does.
Gateshead Health NHS Foundation Trust Trust Headquarters Queen Elizabeth Hospital Sheriff Hill Gateshead NE9 6SX
-2-
Following the inquest and collaboration with the Newcastle Trust, the findings of the inquest have been shared with our District Nurses, to reiterate the process they already follow, including:
• Contacting the inpatient ward for advice (whether that be a ward within this Trust or another Trust);
• Where to locate contact information for the relevant ward; and
• A reminder of signs to look out for with patients who have undergone a femoral endarterectomy.
We have also been liaising with the Newcastle Trust and developed a professional information leaflet for District Nurses which outlines what they should be aware of in relation to this specific procedure in the post operative period and what requires escalation and intervention, We understand you have received this from Newcastle Trust. We have therefore done all we can as a Trust in relation to this concern.
Concern 4: Poor record keeping from the community team which mean that key clinical assessment information was not consistently recorded.
Having reviewed the evidence, we are unable to ascertain where this concern arises from, which makes it difficult to respond directly. However, we would be more than willing to address this further if more detail about the concern could be provided.
As a Trust, we pride ourselves on ensuring that record keeping is a priority. In Mr Nichols' case, key clinical information was recorded, with space to add to pre-populated drop-down boxes and concerns were appropriately raised with the Newcastle Trust, when fresh blood was identified in Mr Nichols' colostomy bag.
As referred to in the inquest, at the time of Mr Nichol's death, the Trust had only very recently moved to a fully electronic records system. This system is now fully embedded and since Mr Nichols' death, 4 years ago, numerous changes have been made to the electronic proformas to strengthen record keeping and capture accurate and key clinical information.
We hope that the above addresses your concerns, but please do revert back to us should you have any further comments or queries with which we can assist.
Sent To
- Gateshead Health NHS Foundation Trust
- Newcastle Upon Tyne Hospitals NHS Foundation Trust
Response Status
Linked responses
2 of 2
56-Day Deadline
2 Nov 2023
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 07/01/20 an investigation was commenced into the death of William Nichols age 66 years. The investigation concluded at the end of the inquest on 20/04/23.
The conclusion of the inquest was: Mr Nichols suffered a catastrophic haemorrhage from the site of a right femoral endarterectomy due to deep patch infection. The significance of blood in the wound discharge at 5 weeks post-surgery having not been acted upon, the opportunity to prevent a fatal outcome was lost.
The medical cause of death was: 1a) Hypovolaemic shock, 1b) Dehiscence of right femoral endarterectomy, 1c) Post-operative deep patch infection,
2) Type 2 diabetes mellitus, rheumatoid arthritis (on Toclizumab), hypertension, ischaemic heart disease and atherosclerosis.
The conclusion of the inquest was: Mr Nichols suffered a catastrophic haemorrhage from the site of a right femoral endarterectomy due to deep patch infection. The significance of blood in the wound discharge at 5 weeks post-surgery having not been acted upon, the opportunity to prevent a fatal outcome was lost.
The medical cause of death was: 1a) Hypovolaemic shock, 1b) Dehiscence of right femoral endarterectomy, 1c) Post-operative deep patch infection,
2) Type 2 diabetes mellitus, rheumatoid arthritis (on Toclizumab), hypertension, ischaemic heart disease and atherosclerosis.
Circumstances of the Death
Mr Nichols underwent surgery, a femoral endarterectomy, on 20/11/19, and developed a lymphatic leak and a post-operative infection, from which he was at an increased risk of developing.
A week prior to his death, Mr Nicholas suffered a herald bleed due to deep patch infection, and on the evening of 02/01/21 Mr Nichols suffered a fatal catastrophic haemorrhage from the site of the right femoral artery. The blood in Mr Nichol’s wound discharge observed on 26/12/19 is likely to have been a herald bleed, and from then Mr Nichols was at a significant risk of catastrophic haemorrhage. On 26/12/19 Mr Nichols should have been instructed to attend hospital immediately where the management would have included an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection.
On 27/12/19 Mr Nichols should have been admitted to hospital. At that point management would have been an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection.
If surgery had been undertaken on 26/12/19 or 27/12/19, or at any time prior to the catastrophic bleed on 02/01/20, the deep patch infection would have been eliminated and it is likely that Mr Nichols would have survived
A week prior to his death, Mr Nicholas suffered a herald bleed due to deep patch infection, and on the evening of 02/01/21 Mr Nichols suffered a fatal catastrophic haemorrhage from the site of the right femoral artery. The blood in Mr Nichol’s wound discharge observed on 26/12/19 is likely to have been a herald bleed, and from then Mr Nichols was at a significant risk of catastrophic haemorrhage. On 26/12/19 Mr Nichols should have been instructed to attend hospital immediately where the management would have included an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection.
On 27/12/19 Mr Nichols should have been admitted to hospital. At that point management would have been an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection.
If surgery had been undertaken on 26/12/19 or 27/12/19, or at any time prior to the catastrophic bleed on 02/01/20, the deep patch infection would have been eliminated and it is likely that Mr Nichols would have survived
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.