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Coroner

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Blackpool Health Trust's poor review poses death risks, says Coroners

Click to read the full article on The BBC Website. 

More patients could die at a hospital unless health bosses review the way serious incidents are investigated, a coroner has warned.

Blackpool coroner Alan Wilson raised his concerns over the internal review into a woman's death following routine surgery at Blackpool Victoria Hospital.

He said Blackpool Teaching Hospitals NHS Foundation Trust's probe into care given to Pamela Briggs was "flawed".

The trust said it has "already begun" a review of its serious incident process.

Missed opportunity

Mrs Briggs' lawyer, Diane Rostron, said she began to suffer with chest pains a week after her operation. 

"An ECG showed irregularities and that was a clear sign she had had suffered a heart attack. Unfortunately she didn't receive any interventional treatment for that. 

"The heart attack was caused by a blocked stent and a simple procedure could have relieved that blockage and may well have ensured Pam survived."

Ms Rostron said the 69-year-old then suffered a second heart attack at St Catherine's Hospice in Preston and died on 13 February after a "crucial window of opportunity" to treat her was missed. 

Mrs Briggs' sister, Chris Walton, said her sibling would still be alive if "appropriate treatment been given" and criticised the trust's investigation for "papering over very serious cracks".

Mrs Walton said the trust took almost seven months to produce its report - contrary to the 60 days in NHS guidelines - and she was "appalled" to discover the probe had been conducted by the doctor and matron responsible for her sister's care - while a key witness was ignored.

"I was dumbfounded; I felt that we were being laughed at," she said.

The coroner has now issued a "regulation 28 report" - a document aimed at preventing future deaths - to the trust and to the chief coroner of England and Wales.

Coroner's concerns 

  • The review was "not robust or thorough enough"

  • Failure to speak to a key witness - the cardiology registrar - meaning the review was based on "inadequate information". The coroner said this meant recommendations were "ill-informed" and "flawed" and "risks placing future patients in jeopardy"

  • One of the authors of the report was the surgeon who operated on Mrs Briggs which risked the perception of a lack of transparency and faith in the recommendations and a risk of failing to amend inappropriate practices

A spokesperson for the trust said the coroner was "not critical of the care given" and found evidence given by staff "extremely helpful" but acknowledged he "expressed some concerns regarding the quality of its incident report".

The trust, which has until January to respond, said a review is under way and "any proposals for changes" will be given to the coroner.

Mrs Walton said: 'This can't all be for nothing. Pam's death has to at least make them look at their actions and change their ways so that future deaths are avoided."

Click to view the video on The BBC Website.

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Risk of future deaths... Coroner's concerns

Pamela died at Blackpool Victoria Hospital earlier this year. Her sister, Christine, was concerned about the care she had received and following extensive enquiries chose me to represent her. The Coroner held an inquest into Pam's death on 4 November. He took the unusual step of issuing a Regulation 28 Report because he was so concerned about the risk of future deaths. I will continue to represent Christine in the months ahead.

Click to read the full article on The Gazette's Website.

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Charlie: Outcome of Coroner's Inquest

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Charlie: Outcome of Coroner's Inquest

Charlie's parents believe that he was let down by the care he received at birth, resulting in brain damage and again when he became unwell at four and a half years of age, resulting in him sadly dying.  Representing our Clients at Coroner's Inquests is part of what we do.   Press release statement issued on behalf of Charlie's parents following the inquest on 10 November 2016, by Diane Rostron.   Charlie was our beautiful little boy. He was born very early and unfortunately we believe that mistakes were made during his delivery causing him to be very badly bruised. In turn, we believe that this caused him to bleed into his brain, causing him brain damage. After many months in hospital he was able to come home with us. Despite his many problems, he was very much loved by us, his parents, and by his brothers and sisters. He was a very important part of all our lives, and his life, although different from able bodied children, was full of joy and purpose.  In March of this year, Charlie became very agitated and upset and we took him into Blackpool Victoria Hospital. He was diagnosed with pneumonia and, against our expectations, was discharged home the same day on an antibiotic. We only agreed to take him home because we were assured that the pneumonia had been caught early and that the antibiotic would soon ‘kick-in’. Unfortunately, his condition deteriorated and the next day we took him back to Blackpool Victoria Hospital. The inquest heard that he was admitted at lunchtime. He was requiring oxygen and was bleeding. Despite this, he was not seen by a doctor until mid-afternoon and no investigations or treatment was provided until early evening. Sadly by then it was too late. He was transferred on a life support system to Alder Hey Children’s Hospital in Liverpool where he died. We were told that he had died from sepsis.  The Coroner decided that he had died of natural causes. It is our sincere belief that his death could have been prevented if our concerns had been listened to and acted upon. We believe that he was let down both at the start and the end of his life. In between he had some very good care from a number of doctors and nurses, and as a family we pay tribute to them. However, we believe that Charlie should not have suffered the brain damage he did at birth and that he should not have died when he did and in the manner he did. We have been assisted by our Solicitor, Diane Rostron, and with her on-going help we will fight for the justice Charlie deserves.   Hospital 'not to blame' for child's death -  Click to read the full article on The Gazette's website.

Charlie's parents believe that he was let down by the care he received at birth, resulting in brain damage and again when he became unwell at four and a half years of age, resulting in him sadly dying.

Representing our Clients at Coroner's Inquests is part of what we do.

Press release statement issued on behalf of Charlie's parents following the inquest on 10 November 2016, by Diane Rostron.

Charlie was our beautiful little boy. He was born very early and unfortunately we believe that mistakes were made during his delivery causing him to be very badly bruised. In turn, we believe that this caused him to bleed into his brain, causing him brain damage. After many months in hospital he was able to come home with us. Despite his many problems, he was very much loved by us, his parents, and by his brothers and sisters. He was a very important part of all our lives, and his life, although different from able bodied children, was full of joy and purpose.

In March of this year, Charlie became very agitated and upset and we took him into Blackpool Victoria Hospital. He was diagnosed with pneumonia and, against our expectations, was discharged home the same day on an antibiotic. We only agreed to take him home because we were assured that the pneumonia had been caught early and that the antibiotic would soon ‘kick-in’. Unfortunately, his condition deteriorated and the next day we took him back to Blackpool Victoria Hospital. The inquest heard that he was admitted at lunchtime. He was requiring oxygen and was bleeding. Despite this, he was not seen by a doctor until mid-afternoon and no investigations or treatment was provided until early evening. Sadly by then it was too late. He was transferred on a life support system to Alder Hey Children’s Hospital in Liverpool where he died. We were told that he had died from sepsis.

The Coroner decided that he had died of natural causes. It is our sincere belief that his death could have been prevented if our concerns had been listened to and acted upon. We believe that he was let down both at the start and the end of his life. In between he had some very good care from a number of doctors and nurses, and as a family we pay tribute to them. However, we believe that Charlie should not have suffered the brain damage he did at birth and that he should not have died when he did and in the manner he did. We have been assisted by our Solicitor, Diane Rostron, and with her on-going help we will fight for the justice Charlie deserves. 

Hospital 'not to blame' for child's death - Click to read the full article on The Gazette's website.

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