Gwendoline Halfpenny

Date of report: 5 December 2017 Ref: 2017-0353 Deceased name: Gwendoline Halfpenny Coroners name: Andrew Haigh Coroners Area: Staffordshire (South) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: University Hospitals North Midlands NHS Trust

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:

Ms Paula Clark, Chief Executive University Hospitals of North Midlands NHS Trust

CORONER

tam Mr Andrew Haigh Senior Coroner for the coroner area of Staffordshire South.

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST

On 25 August 2017 | accepted the transfer from the North Staffordshire Coroner of an investigation into the death of Gwendoline Edith Halfpenny aged 67 years. The investigation concluded at the end of the inquest on 28 November 2017. The conclusion of the inquest was ‘bowel condition of uncertain cause (possibly medication induced) with acute deterioration unable to be effectively treated’.

CIRCUMSTANCES OF THE DEATH

On 1 September 2016 Mrs Halfpenny fell and broke her left arm. Treatment included codeine. On 6 September she was admitted to County Hospital with bowel problems. A decision was made for her to be transferred to the Royal Stoke University Hospital but no bed was available there until the afternoon of 8 September. Her condition deteriorated and at about 6.00am on 9 September she underwent major surgery. She did not recover and died at the hospital on 13 September.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

TWO MATTERS OF CONCERN | would raise with you are as follows —

1. Soon after her arrival at County Hospital Mrs Halfpenny would have benefitted from surgical input. There was no surgical cover at County Hospital. Remote advice from RSUH is not the same as a surgical presence and | wonder if there should be a mid-grade surgical doctor at County Hospital.

2. Back in September 2016 when this death occurred the MEWS systems operated at County Hospital and RSUH differed. This has subsequently been remedied. However | was told at the Inquest that there are still different

policies and equipment at County Hospital than those at RSUH. The hospitals have been part of the same Trust for a considerable period now and | wonder if there should be greater efforts to achieve consistency.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 January 2018. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons: a 2niy), HE (Trust solicitor). | have also sent it to Mr lan Smith HM Senior Coroner for North Staffordshire and the Care Quality Commission who may find it useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

DATE: 5 December 2017

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Andrew A Haigh

HM Senior Coroner for Staffordshire (South) Coroner's Office

No 1 Staffordshire Place

Stafford

ST16 2LP

Tel No: 01785 276127

Fax No: 01785 276128

www .staffordshire.gov.uk sscor@staffordshire.gov.uk