David Curry: Prevention of Future Deaths Report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 25/07/2024
Ref: 2024-0401
Deceased name: David Curry
Coroner name: Jacqueline Lake
Coroner Area: Norfolk
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: The Secretary of State for Department of Health and Social Care
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care: [REDACTED] The Department of Health and Social [REDACTED] | |
| 1 | CORONER I am Jacqueline LAKE, Senior Coroner for the coroner area of Norfolk |
| 2 | CORONER’S LEGAL POWERS I 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. |
| 3 | INVESTIGATION and INQUEST On 05 October 2023 I commenced an investigation into the death of David Alfred CURRY aged 77. The investigation concluded at the end of the inquest on 19 July 2024. The medical cause of death was: 1a) Multi Organ Failure 1b) Urosepsis 1c) Ureteroscopy, Laser Lithotripsy and Insertion of Stent 20.09.2023 1d) Ureteric stent insertion for urosepsis due to an obstructing ureteric stone 07.04.2023 2) Atrial Fibrillation, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease The conclusion of the inquest was: Mr Curry died from recognised risks of an appropriate procedure |
| 4 | CIRCUMSTANCES OF THE DEATH Mr Curry was admitted to Norfolk and Norwich University Hospital on 7 April 2023 when a stone was identified in the left lower ureter and a ureteric stent was placed as an emergency. Mr Curry was referred for a ureteroscopy which was undertaken on 20 September 2023 at Spire Norwich Hospital. Following the procedure Mr Curry showed signs of infection and was transferred to Norfolk and Norwich University Hospital where his condition deteriorated and he died on 1 October 2023. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. Mr Curry was treated for an infected obstructed left kidney and a left ureteric stent was placed as an emergency on 7 April 2023. Mr Curry’s name was added to the NHS waiting list for Day Case urgent left ureteroscopy and laser stone fragmentation. 2. Mr Curry required timely management; coded as Priority (P) 2. P2 is used to denote the ideal time frame for performing surgery and in the event of this procedure, P2 timescale typically means within 4 weeks. 3. Evidence was heard that the risk of post operative urinary infection and sepsis is increased by prolonged stent dwell time. 4 .Due to a lack of theatre capacity, Mr Curry did not receive a date for the proposed procedure at the NHS Trust and some five months following the initial procedure he approached Spire Norwich Hospital on 5 September 2023. The procedure was carried out on 15 September 2023. 5. Following the procedure being carried out Mr Curry developed sepsis and died on 1 October 2023. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by September 19, 2024. I, 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] Norfolk and Norwich University Hospital Legal Team [REDACTED] – Spire Counsel [REDACTED] – Spire Healthcare Centre Legal Team [REDACTED] – Spire Healthcare Centre Legal Team I have also sent it to: Department of Health Care Quality Commission HSSIB (Health Services Safety Investigations Body) Healthwatch Norfolk NHS England (NHS Improvement) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. |
| 9 | Dated: 25/07/2024 Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH |