There has recently been considerable media interest regarding the decision of the Assistant Coroner for Bolton to issue a Regulation 28 report (for the prevention of future deaths) to Wrightington, Wigan and Leigh NHS Foundation Trust.
The Coroner’s concern was in relation to weekend working practices and arose out of evidence given at a three-day inquest which concluded on 22 June 2016 at which I represented the family of the deceased. The inquest heard how Mrs Gleeson was an otherwise fit and healthy 70-year-old who continued working right up until the evening before she went into the Royal Albert Edward Infirmary, Wigan, for a routine hernia operation on the afternoon of Friday 2 October 2015.
Her family visited on Saturday afternoon and were shocked at how unwell she was: she looked white and waxy, and was clammy and in severe pain. She had also been vomiting but had yet to be seen by a doctor that day; the nursing staff had bleeped a junior doctor only to be told that she was prioritising patients.
A doctor did see Mrs Gleeson at 3.15pm and again at 6.30pm but despite Mrs Gleeson’s deteriorating condition it was not until 9.50pm that a further set of nursing observations were taken. By then blood tests had been taken at 9.22pm: although results available at 10.26pm showed that Mrs Gleeson was in severe sepsis, a doctor did not see her until 11.44pm.
A CT scan was arranged and showed that damage to the bowel at surgery could not be ruled out and so a decision was taken to return Mrs Gleeson to theatre although this was not actioned until 4.20am. By now Mrs Gleeson was desperately ill.
She suffered a cardiac arrest when anaesthetic was induced but was resuscitated; when the operation took place surgeons found a large section of necrotic bowel that had been starved of its blood supply since the initial operation due to a mesenteric tear, a rare complication of surgery. This section of necrotic bowel had led to Mrs Gleeson’s severe sepsis. Sadly, she died later that evening.
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Margaret Gleeson with her family
After Mrs Gleeson’s death the Trust put in place its own internal investigation and found a number of failings in Mrs Gleeson’s care including (but not limited to) the following.
- A repeated failure by the nursing staff to complete accurately the Modified Early Warning Score Chart (MEWS) upon which patient observations should be recorded. The purpose of the MEWS chart is to identify patients who are becoming increasingly unwell and ensure that they are brought to a doctor’s attention as soon as possible and kept under review where appropriate.
- Delay in undertaking blood tests.
- Failure to implement aggressive fluid resuscitation.
During the inquest, the Coroner heard evidence which led him to express concern at weekend working practices and staffing.
The consultant surgeon who undertook the hernia operation, gave evidence that at weekends there is only one team looking after all cases, including emergencies, compared to four teams during the week.
He said, with surprising directness, that “the practical consequences are that you don’t give the patients the attention they deserve”. The junior doctor who saw Mrs Gleeson on the Saturday afternoon and evening did not take blood tests and said in evidence that there was simply no time to do this unless they were urgent.
The consultant surgeon who carried out the repair surgery said that the hospital struggles with staff shortages every night shift, not just at weekends, and he had been ‘fighting’ to get an extra doctor on shift in the evenings for two years.
Regulation 28 report
After hearing all the evidence, the Coroner expressed his concerns regarding weekend staffing levels at the hospital.
He explained that he would be submitting a report to The Trust under Regulation 28 of The Coroners (Investigations) Regulations.
The Coroner explained: “Where I am undertaking an investigation and something is revealed by my investigation which gives rise to concern that there is the risk of further deaths occurring or continuing to an extent in the future, and in my opinion action should be taken to prevent those circumstances, then I have a duty to make a report”. There were a number of issues relevant to the Coroner’s decision to proceed with a Regulation 28 report.
First, he accepted my submission that it was not necessary for the concerns he identified regarding weekend working practices to have been causative of Mrs Gleeson’s death and agreed that it was sufficient simply for him to have concern as to the risk of future deaths.
Secondly, the threshold for “giving rise to a concern” was a low one.
Finally, and perhaps most importantly, the fact that there has been much national debate over weekend working in the NHS and therefore the issue is high on the national agenda did not preclude a report: his concern was this hospital and he felt he had a duty to act.
Was weekend working a genuine factor in Mrs Gleeson’s death? This is impossible to know because the reasons for delayed diagnosis or reaction to a deteriorating patient can be varied and not necessarily related to resource issues.
My own view is that Mrs Gleeson’s death was eminently preventable and should have been avoided whether her care was on a weekday or at the weekend. The real failing here was to act on information which was available and which showed she was becoming worryingly unwell.
That said, the comments made by the hospital’s own clinicians were sufficiently worrying that the Regulation 28 report had to be made and it will be interesting to see how the Trust responds.
The report, which I expect to be sent next month, will also be copied by the Coroner to Department of Health, NICE and the CQC. Let us hope that it results in an improvement to patient services.