Darren Goddard
PFD Report
All Responded
Ref: 2020-0060
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 10 May 2020
Coroner's Concerns (AI summary)
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
View full coroner's concerns
(1) TRUS elective surgery ‘consenting’ and information provision (oral and in written format) places a misleading emphasis on flu-like symptoms as adverse effects.
(2) The accuracy of the 1% risk of sepsis incidence provided.
(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.
(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.
(5) Subsequent failure to provide timely and appropriate fluids and antibiotics.
(6) Delay in admission to Critical Care.
(2) The accuracy of the 1% risk of sepsis incidence provided.
(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.
(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.
(5) Subsequent failure to provide timely and appropriate fluids and antibiotics.
(6) Delay in admission to Critical Care.
Responses
Action Taken
The Health Board has agreed to use consistent terminology regarding sepsis and exclude reference to the word 'rarely' on the TRUS biopsy consent form. A single leaflet produced by the British Association of Urological Surgeons (BAUS) is now used. Sepsis training is being reinstated for medical and nursing staff. (AI summary)
The Health Board has agreed to use consistent terminology regarding sepsis and exclude reference to the word 'rarely' on the TRUS biopsy consent form. A single leaflet produced by the British Association of Urological Surgeons (BAUS) is now used. Sepsis training is being reinstated for medical and nursing staff. (AI summary)
View full response
Dear for
We apologise that Mr Goddard's family felt that the reference to 'flu-like' symptoms was misleading: This terminology is used by the Sepsis Trust who advise in their literature that sepsis, in its early stages, is often indistinguishable from flu symptoms: However; the Sepsis Trust also emphasises that patients with these symptoms should seek medical advice urgently. We sincerely apologise that we did not make this clear to Mr Goddard and his family: All patients who have TRUS biopsies are given a Prostate Biopsy Aftercare advice sheet which states that "It is very important t0 see your GP, contact the out of hours service, or attend A&E if you experience symptoms of infection or SEPSIS (e-g: high temperature , feeling hot and cold and shaky, flu-like symptoms) following the procedure_
2. Avoid patients being discharged prematurely We acknowledge, and apologise the conflicting information in the two discharge advice documents which were given to Mr Goddard. The discharge advice leaflet headed Ward 5 stated that patients are expected to be observed for 2-3 hours post procedure , whilst the leaflet provided by the Radiology Department stated that patients normally require monitoring for around an hour: There are no known recommendations from professional organisations as t0 the time period for which patients must be observed prior to discharge. Occasionally men feel light-headed, and bleeding may occur, and patients are generally asked to wait until staff are sure that neither of these occurrences have taken place. The majority of patients will leave before one has elapsed after their procedure, as long as they are feeling well, are able to pass urine and can tolerate oral fluids: Patients will also have their observations taken and these will need to be stable just prior to discharge. It is unlikely that patients will show any evidence of sepsis within this first hour: The Sepsis Trust confirms that patients may show signs of sepsis up to 30 days post procedures. Mr Goddard's passing has reminded us all that sepsis can develop rapidly. We can confirm that a single leaflet; which is produced by the British Association of Urological Surgeons (BAUS) , is now used, which states that patients should expect to go home on the same day, with no specific time scales given.
3. Further training of Triage nursing staff and doctors of the sepsis 6 bundle and for, hour
Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle. Irecently appointed Clinical lead for the Accident and Emergency Department has reinstated ongoing Sepsis training for medical and nursing staff, both agency and substantive. This is currently on hold however due to COVID-19 activity. Locum Doctors are given a Locum doctors advice card, embedded within point 12 of the attached action plan: This highlights the need to ensure that all blood results are reviewed in a timely fashion: will also ensure that point of care testing for venous blood gases is introduced in order to identify abnormal lactate results, which are to the early identification of sepsis: The learning from your report and the University Health Board's own investigations has been shared with individual staff, and also across the organisation via the Health Board's Listening & Leaming Feedback Newsletter: sincerely hope that this information will reassure you that the Health Board has learnt important lessons from the investigation and inquest into the care provided to Mr Goddard and that effective action is being undertaken to prevent further deaths: would like to convey once again my deepest sympathy and sincere apologies to Mr Goddard's family for the failings identified.
We apologise that Mr Goddard's family felt that the reference to 'flu-like' symptoms was misleading: This terminology is used by the Sepsis Trust who advise in their literature that sepsis, in its early stages, is often indistinguishable from flu symptoms: However; the Sepsis Trust also emphasises that patients with these symptoms should seek medical advice urgently. We sincerely apologise that we did not make this clear to Mr Goddard and his family: All patients who have TRUS biopsies are given a Prostate Biopsy Aftercare advice sheet which states that "It is very important t0 see your GP, contact the out of hours service, or attend A&E if you experience symptoms of infection or SEPSIS (e-g: high temperature , feeling hot and cold and shaky, flu-like symptoms) following the procedure_
2. Avoid patients being discharged prematurely We acknowledge, and apologise the conflicting information in the two discharge advice documents which were given to Mr Goddard. The discharge advice leaflet headed Ward 5 stated that patients are expected to be observed for 2-3 hours post procedure , whilst the leaflet provided by the Radiology Department stated that patients normally require monitoring for around an hour: There are no known recommendations from professional organisations as t0 the time period for which patients must be observed prior to discharge. Occasionally men feel light-headed, and bleeding may occur, and patients are generally asked to wait until staff are sure that neither of these occurrences have taken place. The majority of patients will leave before one has elapsed after their procedure, as long as they are feeling well, are able to pass urine and can tolerate oral fluids: Patients will also have their observations taken and these will need to be stable just prior to discharge. It is unlikely that patients will show any evidence of sepsis within this first hour: The Sepsis Trust confirms that patients may show signs of sepsis up to 30 days post procedures. Mr Goddard's passing has reminded us all that sepsis can develop rapidly. We can confirm that a single leaflet; which is produced by the British Association of Urological Surgeons (BAUS) , is now used, which states that patients should expect to go home on the same day, with no specific time scales given.
3. Further training of Triage nursing staff and doctors of the sepsis 6 bundle and for, hour
Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle. Irecently appointed Clinical lead for the Accident and Emergency Department has reinstated ongoing Sepsis training for medical and nursing staff, both agency and substantive. This is currently on hold however due to COVID-19 activity. Locum Doctors are given a Locum doctors advice card, embedded within point 12 of the attached action plan: This highlights the need to ensure that all blood results are reviewed in a timely fashion: will also ensure that point of care testing for venous blood gases is introduced in order to identify abnormal lactate results, which are to the early identification of sepsis: The learning from your report and the University Health Board's own investigations has been shared with individual staff, and also across the organisation via the Health Board's Listening & Leaming Feedback Newsletter: sincerely hope that this information will reassure you that the Health Board has learnt important lessons from the investigation and inquest into the care provided to Mr Goddard and that effective action is being undertaken to prevent further deaths: would like to convey once again my deepest sympathy and sincere apologies to Mr Goddard's family for the failings identified.
Sent To
- Cwm Taf Morgannwg University Health Board
Response Status
Linked responses
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56-Day Deadline
10 May 2020
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 30th April 2019 I commenced an investigation into the death of Darren John GODDARD. The investigation concluded at the end of the inquest on 22nd January 2020.
The medical cause of death provided by the Royal Glamorgan Hospital was:
1(a) Multi-organ Failure; and 1(b) Sepsis (escherichia coli) following prostatic biopsy 1/4/19.
The Coroner’s conclusion at the end of the Inquest was a Narrative Conclusion:
The deceased died from a recognised complication of sepsis following an elective medical procedure. Medical intervention failed to recognise the urgency required for the diagnosis and treatment of sepsis although the impact of this upon the deceased's survival is unclear.
The family’s concerns at inquest were: i) Advice received prior to consenting to the Trans Rectal Ultrasound biopsy (TRUS) procedure was that sepsis was a rare post-procedure occurrence
i.e. the consent form stated a risk of “rarely sepsis“ (Sepsis is a recognised complication following TRUS biopsy occurring in less than 1% of biopsies despite antibiotic cover). Conversely, transient flu-like symptoms were stated as more commonly experienced. This information led Mr.
Goddard to believe the shivers and symptoms he experienced on 1st April 2019 post-operatively were, more likely than not, to be the more common adverse effects of flu-like symptoms rather than the more insidious symptoms of sepsis. The family consider emphasising flu-like symptoms was misleading as they can overlap with the grave symptoms of sepsis thereby minimalizing patient concern and avoiding seeking prompt intervention. ii) Subsequent to Mr. Goddard’s death, the family question how this data i.e.1% is generated and whether or not it is a reliable reflection of the incidence of sepsis following TRUS.
iii) On 29 March 2019, prior to his TRUS procedure, Mr. Goddard was provided a prescription of 4 doses of the antibiotic Ciprofloxacin 750mg. This was considered as being contraindicated for Phenytoin, the anti-epileptic medication prescribed long-term to Mr. Goddard. In the event, and following discussion between the Pharmacy, the Urology Consultant and Nurse Practitioner, it was agreed that Ciprofloxacin was safe to be taken with Phenytoin. The British National Formulary does not list this antibiotic as a contra-indicated medication for Phenytoin.
iv) Mr. Goddard received his antibiotic prescription which he took as prescribed in order to be provided antibiotic prophylaxis for the procedure he was to undergo. The family now have concerns whether the interaction between Phenytoin and Ciprofloxacin 750mgs which was subject of discussions between the pharmacist and Consultant related to any diminished efficacy of the antibiotic.
v) Mr. Goddard underwent TRUS on 1 April 2019 at 1100 hours. He was advised the procedure had been conducted without complication and was discharged at 1300 hours with the warning that he may suffer flu-like symptoms and advised to drink plenty of water. He was discharged from the post-op recovery unit after demonstrating he could tolerate fluids; could produce urine; and had no per rectal bleeding. He was observed for approximately hour post-operatively whereas the recommended observation period was for longer. Had Mr. Goddard been observed for the full recommended period of time his family consider that his early symptoms of sepsis would have been noted in the recovery unit with a good chance of rapid diagnosis and treatment.
vi) The following day, on 2nd April 2019 Mr. Goddard suffered a headache, shaking became incoherent, was bleeding per rectum and in a state of collapse. fearing sepsis rushed her husband to A&E at Royal Glamorgan Hospital. A full account of the TRUS procedure and risk of sepsis was provided to the Nurse at Triage yet there was no sense of urgency with progressing Mr. Goddard for antibiotic treatment and significant delays occurred with being reviewed by a doctor and being administered antibiotics (a delay of 1 hour 40 minutes later than required with the current sepsis 6 management bundle). These delays represented missed opportunities for successfully treating Mr. Goddard.
vii) There was a further significant delay (around 7 hours) in escalating Mr. Goddard for Critical Care by which time he was at risk of heart failure, sepsis and septic shock from a high lactate level (risen to 20).
viii) Although colloidal IV fluids were administered in A&E these were not the recommended fluids for treatment of hypovolaemic shock.
The medical cause of death provided by the Royal Glamorgan Hospital was:
1(a) Multi-organ Failure; and 1(b) Sepsis (escherichia coli) following prostatic biopsy 1/4/19.
The Coroner’s conclusion at the end of the Inquest was a Narrative Conclusion:
The deceased died from a recognised complication of sepsis following an elective medical procedure. Medical intervention failed to recognise the urgency required for the diagnosis and treatment of sepsis although the impact of this upon the deceased's survival is unclear.
The family’s concerns at inquest were: i) Advice received prior to consenting to the Trans Rectal Ultrasound biopsy (TRUS) procedure was that sepsis was a rare post-procedure occurrence
i.e. the consent form stated a risk of “rarely sepsis“ (Sepsis is a recognised complication following TRUS biopsy occurring in less than 1% of biopsies despite antibiotic cover). Conversely, transient flu-like symptoms were stated as more commonly experienced. This information led Mr.
Goddard to believe the shivers and symptoms he experienced on 1st April 2019 post-operatively were, more likely than not, to be the more common adverse effects of flu-like symptoms rather than the more insidious symptoms of sepsis. The family consider emphasising flu-like symptoms was misleading as they can overlap with the grave symptoms of sepsis thereby minimalizing patient concern and avoiding seeking prompt intervention. ii) Subsequent to Mr. Goddard’s death, the family question how this data i.e.1% is generated and whether or not it is a reliable reflection of the incidence of sepsis following TRUS.
iii) On 29 March 2019, prior to his TRUS procedure, Mr. Goddard was provided a prescription of 4 doses of the antibiotic Ciprofloxacin 750mg. This was considered as being contraindicated for Phenytoin, the anti-epileptic medication prescribed long-term to Mr. Goddard. In the event, and following discussion between the Pharmacy, the Urology Consultant and Nurse Practitioner, it was agreed that Ciprofloxacin was safe to be taken with Phenytoin. The British National Formulary does not list this antibiotic as a contra-indicated medication for Phenytoin.
iv) Mr. Goddard received his antibiotic prescription which he took as prescribed in order to be provided antibiotic prophylaxis for the procedure he was to undergo. The family now have concerns whether the interaction between Phenytoin and Ciprofloxacin 750mgs which was subject of discussions between the pharmacist and Consultant related to any diminished efficacy of the antibiotic.
v) Mr. Goddard underwent TRUS on 1 April 2019 at 1100 hours. He was advised the procedure had been conducted without complication and was discharged at 1300 hours with the warning that he may suffer flu-like symptoms and advised to drink plenty of water. He was discharged from the post-op recovery unit after demonstrating he could tolerate fluids; could produce urine; and had no per rectal bleeding. He was observed for approximately hour post-operatively whereas the recommended observation period was for longer. Had Mr. Goddard been observed for the full recommended period of time his family consider that his early symptoms of sepsis would have been noted in the recovery unit with a good chance of rapid diagnosis and treatment.
vi) The following day, on 2nd April 2019 Mr. Goddard suffered a headache, shaking became incoherent, was bleeding per rectum and in a state of collapse. fearing sepsis rushed her husband to A&E at Royal Glamorgan Hospital. A full account of the TRUS procedure and risk of sepsis was provided to the Nurse at Triage yet there was no sense of urgency with progressing Mr. Goddard for antibiotic treatment and significant delays occurred with being reviewed by a doctor and being administered antibiotics (a delay of 1 hour 40 minutes later than required with the current sepsis 6 management bundle). These delays represented missed opportunities for successfully treating Mr. Goddard.
vii) There was a further significant delay (around 7 hours) in escalating Mr. Goddard for Critical Care by which time he was at risk of heart failure, sepsis and septic shock from a high lactate level (risen to 20).
viii) Although colloidal IV fluids were administered in A&E these were not the recommended fluids for treatment of hypovolaemic shock.
Circumstances of the Death
These were recorded as :-
Darren John Goddard 52 years underwent an elective, trans-rectal ultrasound of his prostate gland. A risk associated with the procedure is sepsis. The following day he became acutely unwell and was admitted to the Royal Glamorgan Hospital where upon sepsis was diagnosed but with significant delays with providing intervention. When treatment was provided it was not always the recommended treatment.
Medical intervention failed to improve his condition and he passed away on 18 April 2019.
The Inquest focused upon:-
a. The practices & procedures of the elective surgery of TRUS and information provided concerning sepsis as an adverse effect.
b. Failures within A&E at triage through to critical care to expedite appropriate treatment for sepsis even though warnings of the lethality of sepsis was advertised through public warning notices displayed in the A&E department.
Darren John Goddard 52 years underwent an elective, trans-rectal ultrasound of his prostate gland. A risk associated with the procedure is sepsis. The following day he became acutely unwell and was admitted to the Royal Glamorgan Hospital where upon sepsis was diagnosed but with significant delays with providing intervention. When treatment was provided it was not always the recommended treatment.
Medical intervention failed to improve his condition and he passed away on 18 April 2019.
The Inquest focused upon:-
a. The practices & procedures of the elective surgery of TRUS and information provided concerning sepsis as an adverse effect.
b. Failures within A&E at triage through to critical care to expedite appropriate treatment for sepsis even though warnings of the lethality of sepsis was advertised through public warning notices displayed in the A&E department.
Action Should Be Taken
• Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS and upon their discharge.
• Avoid patients being discharged prematurely.
• Further training of Triage nursing staff and doctors of the Sepsis 6 bundle and ensure the training is kept current.
• Avoid patients being discharged prematurely.
• Further training of Triage nursing staff and doctors of the Sepsis 6 bundle and ensure the training is kept current.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.