Derek Hare
PFD Report
All Responded
Ref: 2016-0018
All 1 response received
· Deadline: 16 Mar 2016
Coroner's Concerns (AI summary)
The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of a critical abdominal issue.
View full coroner's concerns
It would appear that throughout his various admissions to the hospital; two completely separate sets of "notes" were open and used. Thus when the doctor tried to refer to the notes in court he could not do s0 and had to seek a short adjournment to find the relevant entry: If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient: January being
The deceased incessantly asked for appointments at hospital because he knew that his abdomen was "not right" , he was constantly refusedldenied such an appointment: This meant that it is possible that the problem which he had was diagnosed much later than might have been the case, and the outcome might have been different On the 5th 2015 he was admitted via emergency ambulance to TGH with abdominal pains. On the 6" May it was determined that he did not need an emergency colonoscopy and the "urgency was not there He was sent home He attended on the i9" June and had to undergo a laparotomy when the problem of the broken anastomosis was discovered and he died on the twelfth August: It was agreed by one of the consultant surgeons giving evidence to me that it would have benefitted his care to have kept him in hospital on the 6th
The deceased incessantly asked for appointments at hospital because he knew that his abdomen was "not right" , he was constantly refusedldenied such an appointment: This meant that it is possible that the problem which he had was diagnosed much later than might have been the case, and the outcome might have been different On the 5th 2015 he was admitted via emergency ambulance to TGH with abdominal pains. On the 6" May it was determined that he did not need an emergency colonoscopy and the "urgency was not there He was sent home He attended on the i9" June and had to undergo a laparotomy when the problem of the broken anastomosis was discovered and he died on the twelfth August: It was agreed by one of the consultant surgeons giving evidence to me that it would have benefitted his care to have kept him in hospital on the 6th
Responses
Action Taken
The Trust has provided clarification on the issue of separate sets of notes and the actions taken to address the Senior Coroner's concerns, including reinforcement of the record-keeping policy. (AI summary)
The Trust has provided clarification on the issue of separate sets of notes and the actions taken to address the Senior Coroner's concerns, including reinforcement of the record-keeping policy. (AI summary)
View full response
Dear Mr Pollard, Re: Regulation 28: Report to Prevent Future Deaths following Inquest into the death of Derek Edward Hare (Deceased) write further to your letter dated 16"" March 2016 in relation to the Trusts response to your Regulation 28 Report issued following the Inquest; touching upon the death of Derek Edward Hare, on 13" January 2016. am very somy that you cause to contact me again and lhat you found the response given to point of your Regulation 28 Report unsatisfaclory: hope to be able lo address your concerns as set out in section 5 of your report, to your satisfaction in this lelter: With reference to why the response to your Regulation 28 Report typed on the 8" February look a month between typed and being sent to your office, am very for the confusion this caused and would like to assure you that this was a clerical error, and the letter should have been dated 28" February not the 8" February In response t0 1,you staled: It would appear that throughout his various admissions to the hospital, two completely separate sets of "notes were open and used. Thus when the doctor tried to refer t0 the notes in court, he could not do so and had to seek a short adjournment to find the relevant If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient: It was not a question of large case notes which run into two volumes, this was a situation where both sets of notes were apparenty open at the same time and doctors were therefore putting new notes into one or the other but not properly into one single document had being sOrry point being entry:
In respect of your concerns regarding the case notes recognise that staff entries into the records should be in one set of records which should be the current ones in use during the patient's admission This is the Trust's standard and expectation and has been reiterated to the ConsultantClinical Leads, Lead Clinicians and Senior Nurses in the_Clinical Divisions for dissemination to all staff and for discussion at their Clinical Governance and team meetings. As you have highlighted where it is necessary to provide two sets of notes for reference Io the previous history and continuity of care there is a risk that medical staff may enter their notes in the older set of notes This reiteration and reinforcement of the record keeping policy will minimise this. have sought further clarity as you suggested on the problems encountered at Mr Hare's Inquest in this regard and have liaised with Mr Siddiqui. As previously stated two large sets of case notes perlaining to the patient were made available for Inquest: Consultant Mr Siddiqui maintains that he was asked to clarify a date in response to a question raised by Mr Hare's relative. Mr Siddqui informs me that he found it necessary to Iook al the notes which were in a different volume of the case notes ad as such had (o manage both volumes at the Inquest: acknowledge that this was not ideal and further enquiries have informed me that it appears that one set of case notes has records filed up t0 the 27/05/15. This volume held some of the notes Mr Siddiqui had to access (these related to the surgical care) in response to your queslions: The other volume has records up to the patient's death on the 12/08/15. This contained medicine specialty notes and notes where the surgeons had been asked to review Mr Hare) which were also pertinent to the questions asked. am very sorry that Ihis resulted in you having to adjour the Inquest t0 give time for Mr Siddiqui to find the entry and for any inconvenience this caused YOu in respect of your HM Coronial Hearing: also recognise that this gave rise (0 your concerns in relation to the Trusts ability to provide high quality care for the patient 'hope you will find my actions in relation to the concerns you have raised satisfactory: would Iike t0 assure you that have taken your concerns serlously and hope that have addressed your concerns and reassured you of all that the Trust has already undertaken and is currently underlaking, in order to prevent the recurence of similar set of circumstances in the future: Should you have ay further questions arising from the contents of this letter, please do not hesitate t0 contact me_
In respect of your concerns regarding the case notes recognise that staff entries into the records should be in one set of records which should be the current ones in use during the patient's admission This is the Trust's standard and expectation and has been reiterated to the ConsultantClinical Leads, Lead Clinicians and Senior Nurses in the_Clinical Divisions for dissemination to all staff and for discussion at their Clinical Governance and team meetings. As you have highlighted where it is necessary to provide two sets of notes for reference Io the previous history and continuity of care there is a risk that medical staff may enter their notes in the older set of notes This reiteration and reinforcement of the record keeping policy will minimise this. have sought further clarity as you suggested on the problems encountered at Mr Hare's Inquest in this regard and have liaised with Mr Siddiqui. As previously stated two large sets of case notes perlaining to the patient were made available for Inquest: Consultant Mr Siddiqui maintains that he was asked to clarify a date in response to a question raised by Mr Hare's relative. Mr Siddqui informs me that he found it necessary to Iook al the notes which were in a different volume of the case notes ad as such had (o manage both volumes at the Inquest: acknowledge that this was not ideal and further enquiries have informed me that it appears that one set of case notes has records filed up t0 the 27/05/15. This volume held some of the notes Mr Siddiqui had to access (these related to the surgical care) in response to your queslions: The other volume has records up to the patient's death on the 12/08/15. This contained medicine specialty notes and notes where the surgeons had been asked to review Mr Hare) which were also pertinent to the questions asked. am very sorry that Ihis resulted in you having to adjour the Inquest t0 give time for Mr Siddiqui to find the entry and for any inconvenience this caused YOu in respect of your HM Coronial Hearing: also recognise that this gave rise (0 your concerns in relation to the Trusts ability to provide high quality care for the patient 'hope you will find my actions in relation to the concerns you have raised satisfactory: would Iike t0 assure you that have taken your concerns serlously and hope that have addressed your concerns and reassured you of all that the Trust has already undertaken and is currently underlaking, in order to prevent the recurence of similar set of circumstances in the future: Should you have ay further questions arising from the contents of this letter, please do not hesitate t0 contact me_
Sent To
- Tameside Hospital NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
16 Mar 2016
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 19th August 2015 commenced an investigation into the death of Derek Edward Hare dob 15"h August 1937_ The investigation concluded on the 13t 2016 and the conclusion was one of Misadventure: The medical cause of death was Ia Multi organ failure 1b Chest and abdominal sepsis 1c Colonic Anastomotic Failure treated by surgery on 19.6.15: Embolization on 17.4.15 after Colectomy for diverticulitis on 14.1.15 11 Ischaemic Heart Disease.
Circumstances of the Death
Mr Hare was subject to severe abdominal pains and he was admitted to the hospital in January 2015 and was operated on for a colectomy: Thereafter he asked a numerous occasions to see the surgeons again as he was still in pain and was passing blood per rectum, but was refusedldenied the chance to see the doctor: Eventually he was looked at and it was determined that one of his major blood vessels needed embolization: This embolization was done at Wythenshawe Hospital and on his return to Tameside he underwent a colonoscopy to examine the bowel. The embolization had compromised the blood supply to that part of the bowel where the anastomosis had been formed, and when the bowel was inflated for the colonoscopy, it caused the anastomosis to fail leading to a loss of bowel content and the development of sepsis in the abdomen and the chest.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you 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
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Hepatologist Oversight and Fibroscan Access
Infected Blood Inquiry
Delayed Recognition of Deterioration
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.