Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0201, written 5 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Sep 2013 |
|---|---|
| Reference | 2013-0201 |
| Deceased | Labhuden Amarshi Vaghadia |
| Coroner | Catherine Mason |
| Coroner area | Leicester City & South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Acting Chief Executive
Leicestershire Partnership Trust
1
CORONER
I am Mrs Catherine Mason, Senior Coroner, for the coroner area of Leicester City and
South Leicestershire
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 the 3rd September 2012 I commenced an investigation into the death of Labhuben
Amarshi Vaghadia, aged 78 years. The investigation concluded at the end of the inquest
on the 28th August 2013. The conclusion of the inquest was Accidental Death.
4
CIRCUMSTANCES OF THE DEATH
On the 25th August 2012 Mrs Vaghadia attended the Leicester Royal Infirmary Accident
and Emergency department and was diagnosed as having a suspected deep vein
thrombosis in her left calf. She was treated with a subcutaneous anti-coagulant injection
into her abdomen and discharged home for daily follow up injections. Late that evening
and in the early hours of the 26th August 2012 she experienced bleeding from the
injection site. The bleeding had stopped by the time the Community Staff Nurse
attended but she was made aware of the history of bleeding. The nurse proceeded to
give the anti-coagulant injection and telephoned the Out of Hours services to report the
abdominal pain that Mrs Vaghadia was experiencing. A doctor attended later that day
and Mrs Vaghadia was admitted to the Leicester General Hospital where she died on
the 27th August 2012. The cause of death was 1a) haemorrhage and haematoma of the
abdominal wall (injection of Fragmin administered on the 25th August 2012). It is
understood that the injection on the 25th may have punctured a blood vessel or gone into
the muscle. Both would cause bleeding and are recognised risks. However, due to Mrs
Vaghadia’s frailty the problem did not resolve naturally as it normally would.
5
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.
The MATTERS OF CONCERN are as follows. –
administered the anticoagulant on the 26th August 2012
(1) Community Nurse
without seeking medical advice from a Doctor even though she knew Mrs Vaghadia had
been bleeding from the site of the previous injection. Although the expert evidence in
this case is that the nurse’s actions did not cause or contribute to the death in this
instance, there is a risk that such action in another case may not have the same
outcome and could be causative of death.
(2) Although the nurse had full knowledge of the bleeding she did not share this with
other health care professionals when she spoke to them. If she had there was a real
possibility that Mrs Vaghadia would have been admitted sooner. In this instance, the
expert opined that on a balance of probabilities had Mrs Vaghadia been admitted sooner
the outcome was unlikely to have been different. Nevertheless, full and appropriate
information sharing is paramount and the nurse’s actions fell short of her professional
duties and could have caused an adverse outcome.
(3) Nurse
could cause or contribute to death.
(4) Although not causing or contributing to Mrs Vaghadia’s death, it is clear that Nurse
lacks training
appeared to have no professional insight into her actions and that they
actions were not appropriate. I have a concern that Nurse
and/or experience as well as insight that her actions and therefore her practice may
continue and cause future deaths
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 the 23rd October 2013. 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 I have also sent it to
or of interest.
who may find it useful
and
I 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 makerepresentations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
5th September 2013
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Leicestershire Partnership NHS} NHS Trust From the Executive Office A University Teaching Trust Direct dial: 0116 295 0911 Lakeside House Our ref: L111_pm ‘Gore pat Enderby Leicester 17 October 2013 LE19 1SS Tel: 0116 295 0030 Mrs C E Mason Fox 0 earthed H M Coroner Leicester City & South Leicester The Town Hall Town Hall Square Leicester LE1 9BG Dear Mrs Mason Re. Labhuben Amarshi VAGHADIA Thank you for your letter, dated 6 September 2013, with the enclosed Regulation 28: Report to Prevent Future Deaths. | would like to reassure you, and Mrs Vaghadia's family, that Leicestershire Partnership NHS Trust have carefully considered the concerns you have raised, and put actions in place to respond to them. Your concerns | am aware that you are concerned that: 1. Mrs Vaghadia was visited by Community Nurse a... administered a prescribed anti-coagulant injection despite evidence of bleeding from the site of the previous injection; and 2. Nurse reportes to the Out of Hours service that Mrs Vaghadia was experiencing abdominal pain, but did not inform them of the bleeding. Whilst these actions were not causative of Mrs Vaghadia’s death, you are concerned that these actions were inappropriate, demonstrated a lack of professional insight, training and experience and that they could lead to a death in the future. Response The death of Mrs Vaghadia has been reviewed by the following: 1. Community Health Services (CHS) Division Senior Clinical Team 2. CHS Divisional Head of Nursing 3. CHS Clinical Directors Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller 4. CHS Lead Nurses 5. CHS Head of Governance 6. CHS Nurse Consultants 7. Chief Nurse of Leicestershire Partnership NHS Trust (LPT) The CHS leadership has also considered the current practice of the Community Nurses when they attend a patient to administer prescribed medication. It is recognised that it is vital that the Community Nurses ask the right questions to ensure that it is still appropriate to administer the prescribed medication. It is the responsibility of any nurse to work within their Nursing and Midwifery Council (NMC) Code of Conduct. With specific reference to the administration of medicine nurses are required to follow the NMC Standards for Medicines Management, which clearly sets out under Standard 8 the standards for practice in administering medications. These standards include: understanding the therapeutic uses of the medicines being administered; its normal dosage; side effects; precautions and contraindications; administering or withholding medications according to the patient's condition, and contacting the prescriber or another authorised prescriber where contraindications are discovered or where the patient develops a reaction to a medication. The CHS has a Standard Operating Protocol (SOP) for administration of medicines in the community that is aligned to the NMC guidance. CHS Division Community Nurses administer subcutaneous low molecular weight heparin only on the prescription of a prescriber. Usually the prescriber will be a doctor, such as the patients GP, or the prescriber may be a non-medical prescriber such as an Advanced Nurse Practitioner. The responsibility for the prescription ultimately lies with the prescriber. In the case of non-medical prescribing, nurses, who prescribe under this auspice do so only within their competency. | can confirm that if it appears that the administration of the prescribed medication may be contra-indicated the Community Nurses should seek a second opinion from a Nurse Prescriber or Doctor before administering the medication. Full details of all the symptoms should be provided to other professionals to enable appropriate decisions to be made. This applies to anti-coagulant medication where there is evidence of a bleed, and other prescribed medication. Actions Taken It is accepted fully that part of a health professional's responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professional responsibility regarding this issue via a system of email cascade. Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health. All CHS nurses will be re-issued with the SOP and the Divisional Clinical Director will ensure that this communication process is completed by the end of December 2013. All pertinent nursing staff in CHS will be re-issued with the SOP and the matter a topic at the team meetings. CHS lead staff will also be sharing the learning points from the case with nursing and clinical colleagues in all clinical divisions of LPT. For further assurance | advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients’ notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for Chair: Professor David Chiddick CBE Chief Executive; Dr Peter Miller s Moy, *‘ S 3 S = say the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA Community Nurse We have taken a number of steps to address your concerns regarding Nurse HM These include: 1. Two independent assessments of the nursing practice of Nurse by a. The Lead Nurse in the Community Health Service Division; and b. The Clinical Education Lead in the Community Health Service Division. Nurse i clinical skills and competencies were assessed using the Leicestershire Competency Assessment Test (LCAT) that is also used by other NHS organisations. 2. The Divisional Clinical Director and Lead Divisional Lead Nurse HR 22'sonally interviewed Nurs with regard to this matter As a result of this process Nurse is judged to be competent in all areas of clinical practice assessed. However in response to the concerns raised a programme of training has now been arranged for Nurse [EM which includes medicines management training and emotional resilience training. In addition she will participate in additional clinical supervision on a monthly basis for six months and undertake a reflective practice assessment, the sum of which is to strengthen her clinical decision making skills. Yours sincerely, f Dr Peter Miller Chief Executive i Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller 205, Gg LN . VAS 4 say
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