UK Inquiry Tracker

Hannah Barney

PFD Report Historic (No Identified Response) Ref: 2017-0442

Date of Report 11 July 2017

Coroner Andrew Harris

Coroner Area London Inner (South)

Response Deadline est. 5 September 2017

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like necrotising fasciitis.

View full coroner's concerns

_ The MATTER OF CONCERN is as follows_ The plastics surgical consultant_ who saw her on l8th and 2lst gave an opinion that she had haematomas and severe sepsis, although the diagnoses of Fournier$ gangrene or necrotising fasciitis had been considered: These conditions needed very urgent surgical treatment: He said that a few days delay in debridement could make a difference to the damage to surrounding tissues General surgeons are often reluctant to undertake such debridements and may not have the skills. He opined that sole consultant plastics surgeon practitioner in KCH was not safe: In cases of necrotizing fasciitis a small in surgery would mean death: He noted that KCH was a regional trauma centre: He considered future lives were at risk without a 24 hour consultant plastics service at KCH:

Sent To

Department of Health
Kings College Hospital
NHS England

Response Status

Linked responses 0 of 3

56-Day Deadline 5 Sep 2017

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 17th November 2016, I opened an inquest into the death of Ms Hannah Barney, who died on 11.10.15 (027015) (PF) in College Hospital It was concluded on 6th June 2017. The medical cause of death was; la Multi-organ failure 1b Extensive soft tissue bacterial and fungal infection lc Haemolysis, Elevated Liver and Low Platelets syndrome of pregnancy causing liver failure and multiple thrombi; multiple broad spectrum antibiotics I[ Genetic Prothrombotic tendency The conclusion as to the death was by narrative which included: After intensive medical treatment she was initially referred for surgical debridement of an infected groin haematoma on Ilth, which was conducted on I6th and more urgently on I8th, she developed multi-organ failure_

Circumstances of the Death

The evidence of Prof Heneghan was: Between the Ilth and 18th September she was acutely ill and required specialist opinions and multi-disciplinary care: The tissue viability nurse considered urgent surgical opinion was needed on management of her infected wound. She saw a hepatologist and nephrologist on 12th, a weekend surgical team on call on 13th, the team on ISth and a hepato-biliary surgeon in theatre on 16th, The case was then discussed with a plastic surgery registrat, who suggested that an urgent full debridement should be undertaken but this could not be done at King' s College Hospital since there was no on-call plastic cover; and would ultimately need to be performed at St Thomas Hospital. A gynaecology registrar attended on lZth: Ascan was performed to exclude necrotising fasciitis and Kings Enzyme many renal it was agreed that the general surgical consultant would take her to theatre. It was not until l8th when a multi-disciplinary team of gynaecologist, plastics, general surgery and orthopaedics back up was assembled and surgical debridement was performed but she died later in ITU,

Action Should Be Taken

Isend this report to KCH to draw your attention to this reported risk and copy it to NHS England and the Department of Health, as believe that these bodies are in ayposition to take action: