UK Inquiry Tracker

Matthew Simmonds

PFD Report Historic (No Identified Response) Ref: 2014-0119

Date of Report 14 March 2014

Coroner Grahame Short

Coroner Area Hampshire (Central)

Response Deadline est. 9 May 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.

View full coroner's concerns

(1) Hampshire Primary Care Trust (then responsible for commissioning services) carried out a Serious Incident Review as a result of this death and have since into effect an action plan for commissioning services in the case of complex care pathways for discharges to the community particularly in the case of ventilated patients. (2) ! heard evidence that Hampshire Clinical Commissioning Groups as successors to the Primary Care Trust have adopted this plan and that it is working satisfactorily.

(3) The plan was prepared locally and has not been shared with CCG's outside the County. My concern is that to prevent deaths in other parts of the country all Clinical Commissioning Groups should adopt the plan:

Sent To

NHS England

Response Status

Linked responses 0 of 1

56-Day Deadline 9 May 2014

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 17 August 2011 commenced an investigation into the death of Matthew David James Simmonds; age 39. The investigation concluded at the end of the inquest on 14 March 2014. The conclusion of the inquest was that the deceased died due to Interrupted ventilation in a patient dependent on assisted ventilation due to Von Hippel-Lindau Syndrome and recorded a narrative conclusion set out in Box 4 below.

Circumstances of the Death

Matthew Simmonds was suffering from Von Hippel-Lindau Syndrome as a result of which he was quadriplegic and was fully dependent on invasive ventilation He was ventilated by ventilator, which required changing 24 hours, procedure which operated satisfactorily whilst he remained in hospital discharge care plan was put in place on 24 June 2011, by which time his condition had deteriorated to the extent that he had a short life expectancy, but he continued his wish to spend the remainder of his life at home. The limited time before his discharge from hospital contributed to a condensed period for the planning of, and appropriate training for; his care package to be put in place by a provider in the community. Matthew Simmonds was discharged from Southampton Hospital on 6 July 2011 and returned to his home at 68 Oakmount Road, Chandlers Ford, where he was cared for initially by a nurse who had no experience of working in an intensive care or high dependency unit in hospital: He was the same ventilator provided by the hospital successfully during the At approximately 20.00 hours a second nurse arrived at the house. She has intensive care training and experience. The handover was in progress and both nurses were present and assisted when the original ventilator was substituted: Ata time before 21.35 and likely to be about an hour earlier; during the change of ventilators, assisted ventilation to Matthew Simmonds ceased, as a result of the replacement ventilator not being switched to a functioning mode. This fact was not observed until just before 21.35 when the_ventilator was found every using day: to be in stand-by mode and he was seen to be deceased:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action