“Serious error of judgment” in not reporting Northern Trust death to coroner

"We should never have been given an option of whether or not to report it to the coroner" /

By Niall McCracken

THE family of a man whose death is one of 11 under investigation at the Northern Health Trust say they feel “let down by a process which is not fit for purpose.”

The Detail can reveal that 81-year-old Neil Cormican, a grandfather of 17 children, died in April 2010 after he was mistakenly prescribed potassium while being treated at Antrim Area Hospital.

Following his death health staff failed to immediately refer the case to the coroner’s office despite an obligation to do so and gave the family the option of not referring the case.

The deceased man’s daughter Mary Rice said: “Obviously we were in grief at the time and we wanted to take him home, but in hindsight that decision should never have been left for us. They had a statutory requirement to report it the coroner.”

Last week the Health Minister told the Northern Ireland Assembly that he had been made aware of 20 cases in which the Northern Trust’s response to the care of its patients was said to be below standard, 11 of which were deaths.

A review carried out by the Northern Trust into Mr Cormican’s death in March 2011 identified a failure to refer the case to the coroner.

It was weeks before the Coroner’s Service was made aware of his death and six months before it was reported as a Serious Adverse Incident (SAI). SAIs are incidents deemed serious enough to require regional action to improve safety, or be of major public concern or require an independent review.

Mr Cormican’s family say the cases raises questions over not only their father’s treatment, but also about the role the coroner’s service should play in monitoring the deaths reported to the service.

Speaking to The Detail, Mr Cormican’s daughter Mary Rice said she believed her father’s case was the tip of the iceberg and she felt let down by the Northern Trust and the Coroner’s Service.

She called for a change in the system which would ensure that the Coroner’s Office was made aware of all hospital deaths that needed further investigation. Mr Cormican’s inquest took place last year. During the hearing Northern Ireland’s senior coroner, John Leckey, expressed his frustration at delayed referrals and said a failure to report hospital deaths that require further investigation to his office was a “very serious matter” that could warrant police investigation.

Mr Leckey added the decision not to refer was “absolutely wrong and cannot be justified”.

During his evidence at Mr Cormican’s inquest the then Medical Director of Antrim Area Hospital, Dr Peter Flanagan, apologised to Mr Cormican’s family and said it was a “serious error of judgement” to not contact the coroner in this case. Dr Flanagan has now retired from the Northern Trust.

Following last week’s announcement about a number of cases being investigated in the Northern Trust, the Health Minister Edwin Poots said the cases, which date from 2008 until the present, were discovered by a “turnaround team” he had sent to the trust. Eleven of the cases being investigated are deaths and in a statement to The Detail the Northern Trust confirmed that Mr Cormican’s cases was one of the deaths being examined.

A spokesperson for the trust said:

“The Trust can confirm that Mr Neil Cormican was one of the 20 cases referred to in the Minister’s statement. We have met with the family and offered a sincere apology.”

Mr Cormican, from Antrim, died on 15th April 2010 but his death was not reported to the coroner’s office by the hospital until 24th May 2010.

“WE SHOULD NEVER HAVE BEEN PUT IN THAT POSITION”

In March 2010 after a fall at his home 81-year-old Neil Cormican was admitted to Antrim Area Hospital with pneumonia.

During the course of his stay he was prescribed potassium when a blood result which related to another patient was mistakenly entered into his case notes. Within one day of receiving the potassium, he had a cardiac arrest and died.

The normal level of potassium in the blood is between 3.5 and 5.0 mmol per litre. The clinical investigation carried out by the Northern Trust following Mr Cormican’s death found that on the day of his death his potassium level was reported as 7.9mmol per litre and 8.8mmol during the resuscitative attempts that evening.

The family was given the option by hospital staff to take their father’s remains home or face further delay by referring their father’s death to the coroner for a post mortem examination.

Mr Cormican’s daughter Mary says her family should never have been put in that position.

She said: “Obviously we were in grief at the time and we wanted to take him home, but in hindsight that decision should never have been left for us. They had a statutory requirement to report it the coroner.”

Coroners are independent judicial officers who deal with matters relating to deaths which may require further investigation to establish the cause of death.

Doctors, registrars, police officers and funeral directors are required by the Coroners Act (Northern Ireland) 1959 to refer certain deaths to the coroner. These include death by violence or misadventure, as a result of negligence or misconduct or malpractice, due to a work related disease, or if the person has not been seen and treated for the disease causing death within 28 days prior to their death.

The Detail has seen a report on the clinical investigation by the Northern Trust following Mr Cormican’s death. It states that on his admission he “presented as a very ill gentleman with multiple health problems” and said that for the majority of his stay the medical and nursing care “appeared to be of a high standard and resulted in a stabilisation of his health problems and plans to prepare him for discharge home”.However the investigation concluded that human error and poor record keeping had contributed to Mr Cormican being mistakenly prescribed potassium.

It stated that any death associated with an error in clinical management should be reported to the Coroner’s Office and recommended that all consultants should be reminded of their duty to report to the coroner.

When a case is referred to the Coroner’s Service initially a coroner will gather information to investigate whether a death was due to natural causes and if a doctor can certify the medical cause of death. If this is not the case the coroner can order a post-mortem examination.

If it shows that the death was not from natural causes, then a coroner may decide to hold an inquest.

An inquest is an inquiry into the circumstances surrounding a death. The purpose of the inquest is to establish who the deceased person was and how, when and where the death occurred and to provide the required details to the Registrar of Deaths so the death can be registered.

“A VERY SERIOUS MATTER”

Mr Cormican died on 15th April 2010 but his death was not reported to the coroner’s office by the hospital until 24th May 2010.

It was then listed for a full inquest which took place in April last year.

During the hearing Dr Peter Flanagan, the then Medical Director of Antrim Area Hospital, stated that he had incorrectly advised staff not to refer Mr Cormican’s case to the coroner.

In a statement read out during the hearing he said:

“The advice that there was no requirement to contact the Coroner was a serious error of judgement on my part. I accept that unreservedly. A number of factors contributed to that error but principally, I wanted to spare Mr Cormican’s family additional stress at, what was clearly, a very difficult time for them.

“I was aware that Mr Cormican’s family had been fully informed of the circumstances surrounding his death. I was also aware that the trust was committed to carrying out a full and robust investigation into the incident and that Mr Cormican’s family would be kept fully informed of the progress and outcome of the investigation. I wish to apologise formally to Mr Cormican’s family and to the Coroner for the mistake. It is one from which I have learnt and which will not be repeated.”

During the inquest Northern Ireland’s senior coroner, John Leckey expressed his frustration at the delay in the referral of Mr Cormican’s case to his office:

He said: “I have absolutely no doubt that Mr Cormican’s death should have been reported to my office. The practice is a statutory requirement that it should have been, irrespective of what may be agreed between the medical staff and the family.

“And can I just say at the outset: I have concerns that there seems to have been some agreement between the medical staff and the family that there’s no need to report the death to the coroner’s office, and if that happens it will just result in a whole lot of trouble.

“That is absolutely wrong and cannot be justified. And what I consider is, if this has happened once, has it happened before? And if I thought it had happened before, without any hesitation, I would refer this issue to the Police Service of Northern Ireland for investigation, because it’s a very serious matter.”

Mr Cormican’s daughter Mary said she is concerned about the lack of independent investigation carried out by the coroner’s office.

She said: “It makes me feel very angry that this is a system that a lot of people in this country put their trust in. You let doctors look after you but there is no accountability when things go wrong.

“Whether or not I was naïve at the time, but it stands to reason that you would assume that the coroner would have more investigatory powers and they would do that on our behalf.”

Following Mr Cormican’s inquest the family followed up their concerns about the delay of referral in their father’s case directly with the Mr Leckey.

In a letter responding to the family from August last year Mr Leckey said: “I agree there can be a problem in relation to the time interval between a hospital death being reported to my office and statements from the relevant members of staff being received.”

Mr Leckey continued: “In England and Wales there are coroners officers who work in support of the coroner. That may reduce the delay in statements being provided. However there are no coroner’s officers in Northern Ireland and I am unaware of any plans for that situation to change.”

Mary claimed that the current system of reporting hospital deaths to the coroner is too weak.

She said: “The reality is that the coroner’s office hoped that the trust sends them all the information they require and carried out no independent investigation of its own into the death of our Dad.

“What this lack of oversight has meant for my family is that four years later we still struggle to deal with this. We feel let down by a process which is not fit for purpose.”

On Friday the Health Minister told the Northern Ireland Assembly that he was unhappy with governance structures within the Northern Trust.

He said: “The Trust has identified a number of cases where it believes that the quality of care it provided, and/or its previous response to cases where things went wrong, fell below the standard that I, the Trust itself, and most importantly, the population served by the Northern Trust, would and should expect.

“The Trust has identified 20 separate incidents in which the response by the Trust was below standard. These instances were across a number of areas within the Trust including: in obstetrics and gynaecology; imaging; and the Trust’s emergency departments. These incidents involved deaths in 11 cases of which 5 were perinatal deaths.”

The Minister stressed that it was not clear in all of these cases if deaths were avoidable deaths but acknowledged that trust’s response should have been better.

The Minister confirmed that in eight of the cases there were delays in them being reported as Serious Adverse Incidents. SAIs are incidents deemed serious enough to require regional action to improve safety, or be of major public concern or require an independent review.

Mr Cormican died on April 15 2010 and in a statement to The Detail the Northern Trust confirmed that they recorded the death as an adverse incident and it was only reported as a “Serious Adverse Incident” on October 25 2010.

There is currently no requirement under the Serious Adverse Incident procedure to inform the coroner of a death resulting from a SAI.