Dorothy Breislin
PFD Report
All Responded
Ref: 2017-0348
All 1 response received
· Deadline: 8 Apr 2018
Coroner's Concerns (AI summary)
There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.
View full coroner's concerns
During tne course of the inquest the evidence revealed matters giving rise to concern. In opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory to report to you: _ The incident date was 27th January 2015. The Incident Review Report was not received in this office until 10th August 2017 . Why the delay? S.13 recites an apology has been provided verbally and in writing: The families ask who made the apology. Also, when and where as are adamant they have never received one confirmed on oath that none of the Action Plan referred to in the Appendices at 3 have been implemented: If not;, in view of the Incident Date why not? of the Incident Review Report is attached for ease_
Responses
Action Planned
The Trust is implementing a new SI process which incorporates training across the Trust and a new Risk Manager will start in February 2018. The updated clerking proforma risk assessment will be sent to stores to be re-printed and then circulated to the clinical teams. (AI summary)
The Trust is implementing a new SI process which incorporates training across the Trust and a new Risk Manager will start in February 2018. The updated clerking proforma risk assessment will be sent to stores to be re-printed and then circulated to the clinical teams. (AI summary)
View full response
Dear Mr Cooper write further to Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mrs Breislin. Matters_of_concern The_incident date was 27_January 2015 The_incident review report was not received in this office until 10 August 2017. Why_ the delayz can only apologise for the unacceptable delay in not only recognising that this was an Sl but for the delay in forwarding the final report to you. The Trust recognises that the Sl process at that time was poor. We are working hard to clear our backlog of Sl reports; which is being overseen by myself and the Director of Nursing and we are also implementing a new Sl process_ This incorporates training across the Trust on undertaking Sl investigations We currently have an Interim Director of Governance in post who is leading on this project and a new Risk Manager will be starting in February 2018. Whilst this is a work in progress, [hope you will be assured that the Trust is striving towards a much improved Sl process_ 2 S13 recites an apology_has been provided_verbally and in writing The_family asks who_made_the apology Also_when and_where as they are adamant have_never received one This Duty of Candour section is what should_have happened. have no evidence that any verbal apology was made and indeed a written apology should have been done, but was not. Again; can only apologise that what we should have done was Chairman: Dean Fathers MINDFUL Chief Executive: Jan Sobieraj (Mr) EMPLOYER 915aBL69 your they About
not done 3 confirmed on oath that none_of_the_Action Plan referred_ to_in the Appendices at 3 have_been implemented lfnot_in view of the incident date_why not? The VTE Nurse Manager and the Consultant Haematologist met up in August 2017 to discuss the changes and these were agreed: This was to be discussed at the September 2017 Thrombosis Committee meeting but the meeting was cancelled as both the Chair and Vice Chair were unable to attend. Unfortunately, due to an oversight the matter was not onto the November agenda. This was picked up in December 2017 when the form was sent to (Consultant Physician) to update the clerking proforma risk assessment; understand that the updating clerking proforma was to go to and be available for use in January 2018. have been advised that the revised risk assessment will be sent to Stores to re-print on Monday 29 January 2018 and then be circulated to the clinical teams
not done 3 confirmed on oath that none_of_the_Action Plan referred_ to_in the Appendices at 3 have_been implemented lfnot_in view of the incident date_why not? The VTE Nurse Manager and the Consultant Haematologist met up in August 2017 to discuss the changes and these were agreed: This was to be discussed at the September 2017 Thrombosis Committee meeting but the meeting was cancelled as both the Chair and Vice Chair were unable to attend. Unfortunately, due to an oversight the matter was not onto the November agenda. This was picked up in December 2017 when the form was sent to (Consultant Physician) to update the clerking proforma risk assessment; understand that the updating clerking proforma was to go to and be available for use in January 2018. have been advised that the revised risk assessment will be sent to Stores to re-print on Monday 29 January 2018 and then be circulated to the clinical teams
Sent To
- Lincolnshire Hospitals NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Apr 2018
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 3r February 2015 | commenced an investigation into the death of Dorothy Doreen BREISLIN, age 89. The investigation concluded at the end of the inquest on 29th November 2017 . The conclusion of the inquest was Narrative_
Circumstances of the Death
The deceased was admitted to the Pilgrim Hospital; Fishtoft on 18th January 2015 following a fall at home She was initially treated for a pulmonary embolism. A later diagnosis revealed a fracture of the 8th rib on the right side that led to massive bleeding and eventually her demise_ 4 Lindum Road; Lincoln, Lincolnshire, LN? 1NN TEL: (01522) 552500 FAX: (01522) 516055 E-Mail: LincsCoroner@lincolnshiregov uk
Stuart P G Fisher HM Senior Coroner County of Lincolnshire
Stuart P G Fisher HM Senior Coroner County of Lincolnshire
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action:
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Robust debrief systems for multi-agency exercises
Manchester Arena Inquiry
No open learning culture
Major project lessons learned
National systems to record lessons from exercises
Manchester Arena Inquiry
No open learning culture
Major project lessons learned
Obtain comprehensive accounts from commanders
Manchester Arena Inquiry
No open learning culture
Major project lessons learned
Address BTP systemic failings from Volume 1
Manchester Arena Inquiry
No open learning culture
Major project lessons learned
Review international practice on medics with firearms officers
Manchester Arena Inquiry
No open learning culture
Major project lessons learned
LRF oversight of lessons from exercises and incidents
Manchester Arena Inquiry
No open learning culture
Major project lessons learned
Establish a managed safety programme to implement inquiry recommendations
Fennell Inquiry
No open learning culture
Major project lessons learned
Uniform policy for obtaining technical advice
Scottish Hospitals Inquiry
Major project lessons learned
Streamlining NHS construction quality procedures
Scottish Hospitals Inquiry
Major project lessons learned
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.