Date of report: 09/02/2023
Deceased name: George Kearsey
Coroner name: Graeme Irvine
Coroner Area: East London
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Barking, Havering & Redbridge NHS Trust and Department of Health and Social Care
|REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
|THIS REPORT IS BEING SENT TO:
[REDACTED] CEO, Barking, Havering & Redbridge NHS Trust
[REDACTED] RT Honorable Therese Coffey, Secretary of State for Health & Social Care
I am Graeme Irvine, senior coroner, for the coroner area of East London
|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. htt p:/ / www.legislat ion. gov.uk/ukpga/2009/ 25/ sc hedule/ 5/ paragraph/7 htt p:/ / www.legislat ion .gov.uk/uksi/2013/1629/part/7/made
|INVESTIGATION and INQUEST
On 10th June 2022, this court commenced an investigation into the death of George Frederick Kearsey aged 87 years., The investigation concluded at the end of the inquest held on 8th February 2022. I made a determination of a short form conclusion of accidental death.
Mr Kearsey’s medical cause of death was determined as;
I a Aspiration Pneumonia
1b Dementia, left sided 7th and 8th rib fractures.
II Type 2 Diabetes, Chronic Kidney Disease , Aortic Stenosis, dehydration
|CIRCUMSTANCES OF THE DEATH
George Frederick Kearsey sustained injuries in a fall at home on 20 May 2022. The deceased was taken to hospital by ambulance on 21 May 2022. After preliminary diagnostic tests he was admitted into hospital to allow pain management whilst awaiting an MRI scan.
Mr Kearsey developed aspiration pneumonia and was thereafter ordered nil fluids by mouth. As a consequence of this decision, he was prescribed Iv fluids.
Mr Kearsey deteriorated and died on the evening of 8 June 2022.
During the course of the inquest the evidence 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. IV fluids were not administered consistently. The longest period in which fluids were not administered was 17 hours and 45 minutes.
2. Contrary to Trust policy, fluid balance charts were not put in place to assess Mr Kearsey’s fluid intake and output.
3. Clinical records were poorly maintained , resulting in an unclear picture of fluid administration.
4. Consultant-led ward rounds did not adequately review fluid monitoring.
|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.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 7th April 2023. 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.
|COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Kearsey, the Care Quality Commission. I have also sent it to the local Director of Public Health 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 other 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 elieves may find it useful or of interest.
You may make representations to me, the coroner, at the tim of your response, about the release or the publication of your response.
|[DATE] 9th February 2023 [SIGNED BY CORONER]