Kelly Willis
PFD Report
All Responded
Ref: 2015-0122
All 1 response received
· Deadline: 11 May 2015
Coroner's Concerns (AI summary)
Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent deterioration.
View full coroner's concerns
In these circumstances it is my statutory duty to report to you _ Those caring for Mr Willis at William Harvey Hospital recognised the need to contact St Thomas' Hospital about the procedure that he had undergone there but failed to liaise with the tertiary centre before 2gth October; even though this was well documented in the medical records on the first and third admissions that it should be am of the opinion that contact with the tertiary centre which had operated on Mr Willis should have been made when he first presented at William Harvey Hospital on 4th October, and thereafter on 22nd October and on 25th October as Dri had requested_ Dr did not act on the email sent to her by Dr Had she liaised with him it is likely, given his flu-like illness and increasing white cell count; that he would have been investigated with CT imaging either at St Thomas' Hospital or William Harvey Hospital at an earlier stage than 29h October, thus allowing the opportunity to Drl to exclude rare complications, as he requested in his email to Dr
Responses
Action Planned
East Kent Hospitals will include an article in the "Risk Wise" publication reminding staff of the importance of reassessing and completing outstanding actions, and considering contacting tertiary treatment centers for guidance. They also highlight existing handover and review processes. (AI summary)
East Kent Hospitals will include an article in the "Risk Wise" publication reminding staff of the importance of reassessing and completing outstanding actions, and considering contacting tertiary treatment centers for guidance. They also highlight existing handover and review processes. (AI summary)
View full response
Dear Ms Redman Re: Kelly Patrick WILLIS (deceased) Following the conclusion of the Inquest hearing touching upon the death of Kelly Willis on 25th March 2015 and pursuant to Paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009, and to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, set out below the actions and considerations taken by East Kent Hospitals University NHS Foundation Trust in respect of your findings. 1, Follow up of documented actions There are regular, daily handover sessions between the separate clinical and nursing staff when there is a change over in shift pattern of staff covering the hospitals' sites During these handover sessions it is expected that staff inform those coming on duty of any outstanding actions to be taken in respect of the individual patients on the wards_ This includes informing staff of the importance of following up any actions which remain outstanding at the time of handover: In addition, clinical staff are expected to review the more recent entries within a patient's healthcare record at the time when attend to a patient, in order to ensure that are aware of the pre-existing documentation within the patient's healthcare records and to assist in informing future clinical decisions which may need to be taken: At the time when reviewing the healthcare records, and where it is observed that an action is outstanding, consideration is given as to the appropriateness of furthering the action in view of the patient's current clinical condition: Where there is concern as to the appropriateness of following up a documented action, it is my expectation that the individual's concerns are escalated to a senior member of staff for further consideration/discussion. Any revisions to action plans should be clearly documented within healthcare records to not only record the care decided upon and given, but also to inform future decision making and on-going treatment plans.
2. Prompt Contact with Tertiary Referral Centres The Trust recognises that earlier contact should have been made with at St Thomas' Hospital following Mr Willis' admission to the William Harvey Hospital, particularly because his diagnosis was unconfirmed. It is not uncommon for patients to undergo treatment at tertiary centres and for their care to subsequently be referred back to that of the Trust either as a direct referral or following readmission to hospital from the community setting, as in Mr Willis' case It is not mita Puttina Datients first they they the
Rachel Redman 07 2015 Page 2 appropriate or necessary for contact with tertiary centres to be made for all patients who subsequently return to our care, but it is appropriate in circumstances where patients suffer rare complications of procedures which have undergone,such as in the case of Mr Willis_ fully understand that had timely contact been made with Mr Willis may have been offered further treatment for his condition and whilst the prognosis of long term survival would have been poor; he may have received alternative clinical care and management In order to bring your concerns to the attention of the clinical and nursing staff within the Trust an article will be included in the regular publication produced by the central Risk Management Team entitled Risk Wise. This publication is disseminated electronically to all members of Trust staff and is produced on a quarterly basis. The article will include reminders to all staff of the importance of ensuring that requested actions which are either documented within the healthcare records or advised of during handover sessions, and which appear to be outstanding at the time of review are reassessed with a view to subsequent completion: The article will also inform the reader of the importance of considering the need to make contact with tertiary treatment centres for further guidance and patient management, particularly where a patient has already received treatment from that centre. A copy of the published bulletin will be sent to you in due course. would like to take this opportunity to thank you for your letter and to reassure you that we have taken your comments on board and will continue our commitment to deliver a safe and effective service to our patients_
2. Prompt Contact with Tertiary Referral Centres The Trust recognises that earlier contact should have been made with at St Thomas' Hospital following Mr Willis' admission to the William Harvey Hospital, particularly because his diagnosis was unconfirmed. It is not uncommon for patients to undergo treatment at tertiary centres and for their care to subsequently be referred back to that of the Trust either as a direct referral or following readmission to hospital from the community setting, as in Mr Willis' case It is not mita Puttina Datients first they they the
Rachel Redman 07 2015 Page 2 appropriate or necessary for contact with tertiary centres to be made for all patients who subsequently return to our care, but it is appropriate in circumstances where patients suffer rare complications of procedures which have undergone,such as in the case of Mr Willis_ fully understand that had timely contact been made with Mr Willis may have been offered further treatment for his condition and whilst the prognosis of long term survival would have been poor; he may have received alternative clinical care and management In order to bring your concerns to the attention of the clinical and nursing staff within the Trust an article will be included in the regular publication produced by the central Risk Management Team entitled Risk Wise. This publication is disseminated electronically to all members of Trust staff and is produced on a quarterly basis. The article will include reminders to all staff of the importance of ensuring that requested actions which are either documented within the healthcare records or advised of during handover sessions, and which appear to be outstanding at the time of review are reassessed with a view to subsequent completion: The article will also inform the reader of the importance of considering the need to make contact with tertiary treatment centres for further guidance and patient management, particularly where a patient has already received treatment from that centre. A copy of the published bulletin will be sent to you in due course. would like to take this opportunity to thank you for your letter and to reassure you that we have taken your comments on board and will continue our commitment to deliver a safe and effective service to our patients_
Sent To
- East Kent Hospitals University NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
11 May 2015
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 15 September 2014 commenced an investigation into the death of Kelly Patrick WILLIS. The investigation concluded on 25 March 2015. reached a narrative conclusion; a copy of which is attached.
Circumstances of the Death
Kelly Patrick Willis underwent ablation for atrial fibrillation at St Thomas' Hospital on 8th October 2012. He was discharged the following Dr the Consultant Cardiologist and Electrophysiologist who operated on him emailed Drh Consultant Cardiologist at William Harvey Hospital on 10th October and advised her that if Mr Willis began to feel unwell after a period of one week that he should be contacted to exclude 'rare complications (e.g: atrial oesophageal fistula)' Mr Willis developed symptoms of general unwellness which required him to be admitted to William Harvey Hospital on 14th October; 22nd October and 25th October: On the first and third admission it was noted on admission that he had undergone a procedure at St Thomas' Hospital who should be contacted. In spite of this documentation, it was not until Drl reviewed the patient on 29th October that contact was made with St Thomas' Hospital, Dr was unable to account for when she read Dr Jemail and the Ward Clerk, at the end of the second admission; was requested to fax a copy of the Electronic Discharge Notification to St Thomas' Hospital but failed to do so for a further seven days until 30th October. The cause of death was: 1a) Cerebral infarction 1b) Multiple septic emboli Ic) Atrio-oesophageal fistula complicating atrial ablation (08.10.12) for paroxysmal atrial fibrillation. day:
Action Should Be Taken
believe that if it is documented in the medical records that action should be taken, then that request should be followed: consider that early contact should be made with tertiary centres which have carried out procedures or treatment in circumstances where their patient is subsequently admitted to William Harvey Hospital without a confirmed diagnosis.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.