Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0239, written 14 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2013 |
|---|---|
| Reference | 2013-0239 |
| Deceased | Yousef Shokri-Gharab |
| Coroner | Andre Rebello |
| Coroner area | Liverpool |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Mersey Care, NHS Trust, Windsor House 40 Upper Parliament Street Liverpool L8 7LF 1 | CORONER lam André Rebello, Senior Coroner, for the area of Liverpool 2 | CORONER’S LEGAL POWERS | 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 ‘1st July 2013 | commenced an investigation into the death of Yousef SHOKRI- GHARAB, Aged 34. The investigation concluded at the end of the inquest on 11th October 2013. The conclusion of the inquest was la Morphine (Heroin) Toxicity Yousef SHOKRI-GHARAB was certified as having died at the Royal Liverpool University Hospital on the 20th June 2013. He was an asylum seeker from Iran and his request for asylum status had been rejected by the Home Office. He was going through a tribunal | appeal against this decision at the time of his death. He was suffering from a mentai illness which, though still under assessment, was in the nature of an emotional unstable personality disorder. He had difficulty in coping with stress, had poor coping strategies, difficulty regulating his emotions and had hallucinations. He had self-harmed in various ways including overdoses of medication, banging his head, striking hard objects with his hands and fists and cutting himself with parts of a sharp tin-can. It remains unclear as to whether his self harm was purely part of his mental! disorder or attention seeking or to manipulate situations. It is unclear as to whether he intended to end his life through self harm or whether comments about ending his life were made to exaggerate his demands. He required in-patient treatment for this disorder, to which he agreed without need for recourse to the statutory powers. He reported that he had previously suffered and received treatment for substance misuse, including heroin, but had been abstemious for a year and a half. He was on level two observations which precluded him having unescorted leave from the Windsor House until 13th June, when a multidisciplinary team appropriately moved him to level one observations enabling leave. Unfortunately "the Policy and Procedure for leave for an informal patient" in the hospital, ratified in October 2006 and due for review in October 2007, remained the current policy in June 2013, it not having been reviewed. Permission for leave on the 15th, 16th, 17th 19th and 20th June 2013 were authorised after consideration and risk assessment by nursing staff, without regard to the opinion of the Responsible Medical Officer (Consultant Psychiatrist). In this case it is found that this did not make any material difference to what would have happened had the policy been followed as the consultant psychiatrist confirmed that he would have approved of the leave granted. This would not necessarily have been the outcome in another case. On the 15th, 16th, twice on the 17th and on the 19th June, Mr SHOKRI-GHARAB returned from leave. There was no reason why he would not have been given leave to ostensibly visit the post office, Refugee Action and his solicitor on the 20th June to clarify payments of his asylum support allowance. It is unclear as to whether he attended at any of these places when on leave. He was found at about 12.15 pm in a collapsed state in a disused car park in Roscoe Street, Liverpool 1. Thereafter, he was attended by paramedics and taken to the Royal Liverpool University Hospital. At 13.25, after attempts at resuscitation, he was certified as having died. Post mortem analysis of blood revealed, amongst other substances, the presence of Morphine at 0.36 mg/L, 6-mono-acetyl Morphine at0.008mg/L, Codeine at .0.027mg/L. It is found that Yousef SHOKRI-GHARAB has died from the toxic effects of heroin. It is likely to be significant that he had been abstemious from opiates for 18 months and was likely to have lost any tolerance to opiates which he previously had. CIRCUMSTANCES OF THE DEATH Yousef Gharaab is an asylum seeker, his asylum seeker status has recently been reviewed and rejected. H s family have been concerned as he has shown suicidal intent, stating he will end his life by any means. He has recently been discharged from the Brunswick Ward at Windsor House on 31st May 2013. On Thursday 20th June 2012 and his partner Vere sleeping rough at the old car park junction of Oldham street and Roscoe street. They awoke at 12.15pm and noticed a male was on the floor, he looked asleep but John didn't recognise him. John noticed his lips were purple and he wasn't breathing. Paramedics were called and conveyed Yousef to RLUH where he died short time later. ond Hconfirmed death not being treated as suspicious after visiting the scene and not finding any suspicious marks or injuries. 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. — The Mersey Care Policy and Procedure for leave for an informal patient was ratified in October 2006 and was due for review in October 2007. It has not been reviewed. The. policy does not reflect practice. The policy needs to be updated immediately to protect patients and to be fair to employees of Mersey Care. To reflect current practice the policy should reflect amongst other matters that leave is permitted when observations are reduced to level 1 and there has been a multidisciplinary team consensus that a regime of leave is appropriate having consideration to (i) the deceased's vulnerability, (ii) the fact that the hospital had assumed responsibility for the patient's welfare and safety, including by the exercise of control, and (iii) the nature of the risk and whether it was “exceptional” rather than “ordinary” The policy should include stressing the importance of documenting before leave the time of taking leave and when the patient is due back. The operation of the policy should be audited to ensure compliance. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd December 2013. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Yousef Shokri-Gharab The Home Office The Coroner's Society | 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 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. Jaen DATE SIGNED BY CORONER: 14" October 2013
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BCUHB c/o Litigations, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham 1 CORONER 1am JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East and Central)] 2 | CORONER’S LEGAL POWERS | 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 19" of April 2013 | commenced an investigation into the death of Gwilym Pugh Jones (DOB 24.2.40, DOD 16.4.13). The investigation concluded at the end of the inquest on the 19" of September 2013. The conclusion of the inquest was Accidental Death and the medical cause of death was 1(a) Sepsis 1(b) Peritonitis and Toxic Mega Colon 1(c) Pseudomembranous Colitis (Clostridium Difficile Infection) 2 Diabetes Mellitus and Lacunar Anterior Circulation Stroke. 4 | CIRCUMSTANCES OF THE DEATH 1. The Deceased had been admitted to the Wrexham Maelor Hospital on the 44" of March 2013 due to an apparent stroke. Whilst a patient at this hospital he developed symptoms which were suggestive of the Clostridium Difficile infection and on the 11™ of April by an attending clinician that a stool sample be sent for analysis. This was not done. 2. At the final inquest hearing evidence was given by 7/9 regarding the treatment of Mr Jones and he was unable to account for the failure of obtaining and testing a stool sample and he indicated that it is possible that the final outcome may have been different had this condition been diagnosed and treated sooner. 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. — (1) Tests were not conducted despite being required by a clinician and this resulted in a missed opportunity to provide a diagnosis and treatment. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20" November 2043. 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — wife of the Deceased) tam 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 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. [DATE] 25" September 2013 [SIGNED BY CORONER] GAA
2 responses 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.
Bwrdd lechyd Prif | Ysbyty Gwynedd, Penrhosgarnedd, rdd lechyd Prifysgo Bangor, Gwynedd, LL57 2PW Betsi Cadwaladr >7 WAL University Health Board Gwynedd Hospital, Penrhosgarnedd, ES Bangor, Gwynedd, LL57 2PW PRIVATE & CONFIDENTIAL Mr John A. Gittins GORONERS DEPT County tall <1 SUN 2014 Wynnstay Road Ruthin ee LL15 1YN Dyddiad/ Date: 9" June 2014 Dear Mr Gittins Re: Request for information in response to your Requlation 28 report for the Prevention of Future Deaths in relation to the death of Mr G. P. Jones. Thank you for your letter of 25"" September 2013, including the Report for the Prevention of Future Deaths. The Health Board appreciates the concerns that you have raised around potential risks for other patients and have considered all the issues carefully. | apologise for the delay and thank you for allowing the extra time for the Board’s response to be submitted. You indicated in the Report that your concerns related to: (1) Tests were not conducted despite being required by a clinician and this resulted in a missed opportunity to provide a diagnosis and treatment. A full investigation has been undertaken by the Clinical Programme Group (CPG) for Primary Community and Specialist Medicine (PCSM) and also the Infection Control and Prevention Team, addressing the issues as to why, despite three requests from the Doctor, for stool samples to be taken for this gentleman, (so that they could be sent for analysis), this was not carried out. The Governance Lead for Primary Community and Specialist Medicine Clinical Programme Group (East region) has met with the Matron for the ward area concerned, Bersham Ward at the Maelor Hospital, to discuss this matter. During the discussion, it was ascertained that there were three occasions, over three separate days during the patient's admission, where it was documents in his medical records that a stool sample was required. This request had been made by the Clinician caring for Mr Jones, so that it could be tested for Culture, Sensitivity and Clostridium Difficile. The request had been noted in the Multidisciplinary Team (MDT) section of his records in accordance with usual practice. All Registered Nurses are aware that they are required to check the MDT section of a patient's medical records as this is where requests and changes to a patient’s plan of care are documented by the Clinical Teams. Nursing staff are required to check these notes, Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk Qn, G IG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr 4 H University Health Board WALES as a minimum, on a daily basis to ensure that they are fully aware of any requests or updates from other members of the MDT. It therefore appears that the request for a stool sample was an omission on the part of nursing staff. This has been discussed with them, both individually and collectively, and their practice is being monitored by the Ward Sister who has implemented an improvement plan which includes a training programme for all staff. The Ward Sister has provided an assurance to the Matron that staff are now aware of their responsibilities with regards to the obtaining of samples. Prior to the holding of the Inquest into the death of Mr Jones, the Ward Sister from Bersham Ward attended a Root Cause Analysis (RCA) meeting, the purpose of which was to look at the issues raised regarding this patient’s care. The meeting was organised by the Infection Control Team and, following discussion at this meeting, there appeared to be no clear reason as to why the task of obtaining a stool sample had not been undertaken by nursing staff. The meeting was also attended by the Consultant who cared for this patient. As a result of the RCA meeting and subsequent discussions, it was identified that some members of staff were not fully up to date with their mandatory Infection Control training. This has now been addressed and all staff received up to date training by 3 December 2013. Infection Control training rates are now monitored on a monthly basis across the CPG by Matrons and Lead Nurses and scrutinised at the CPG Quality and Governance meeting. There are also paper copies of the relevant Infection Control and Prevention Policies on the ward, which will guide staff on how to manage the process of obtaining samples. Staff members also have access to these Policies on line on each ward via the BCUHB intranet. All staff members employed by BCUHB are required to undertake the Health Board’s Induction Programme which includes mandatory Infection Control and Prevention training. In the past, these meetings have been organised by the Infection Control team who would invite staff from the CPG. However, to ensure ownership by the CPG, the Associate Chief of Staff Nursing for the CPG has instructed that in future the Governance Lead for each site will now be responsible for organising these meetings. The Matron and Ward Sister have provided further assurance to the Lead Nurse that the practice of obtaining samples has improved. This has been measured anecdotally at ward level by senior staff and through interaction with the Infection Control and Prevention Team. This improvement has also been reflected in the number of DATIX (incident reporting database) reports relating to delays or issues with obtaining samples which in this specific area has dropped to zero since the incident date. . Following the Inquest on Mr Jones, the Governance Lead has spoken at length with the local Infection Control Team who do not feel that there are any specific issues on Bersham Ward at the current time and that there are no concerns regarding the practice of ward staff. This has been based on their ward level experience of working with the nursing staff, Bwrdd lechyd Prifysgol Betsi Cadwaladr — 4 University Health Board WALES including the Ward Sister, and on their own audits. The team have also noted that there have been no periods of increased incidence relating to Clostridium Difficile since this incident. The Infection Control team further commented that they feel that the practice of obtaining samples has improved markedly on Bersham Ward. This follows a meeting between the Infection Control team and ward staff to discuss the need and importance of ensuring that samples are sent in a timely manner. The Matron for the relevant area PF has written to all staff on Bersham Ward individually outlining the concerns regarding the failure to obtain stool samples for this patient. The letter reminded staff of their duty of care to undertake investigations in a timely manner. A copy of this letter is attached, together with a copy of the signature sheet which staff were required to sign when they had read their letter (items 3 and 4 attached to the action plan). Matron Ha :2: also directed that the issue was to be on every Safety Briefing for a period of four weeks therefore a memo was distributed to all Clinical areas within the PCSM CPG (East), outlining the matter (number 5 on the attached action plan). The Safety Briefing is held a number of times each day with all members of the ward team and is designed to highlight to staff any patients with issues of concern as well as sharing important ward information, for example follow up actions and infection control matters. A copy of the format of the Safety Briefing is attached for information (number 6 on the action plan). There are also a number of Policies which guide staff on the prevention and control of infection. In these Policies the standard procedures for obtaining samples and managing infectious conditions are clearly set out for staff to follow. As stated above, these are readily available in the ward area and online and staff are expected to adhere to these processes. The Policy concerning the management of suspected and confirmed Clostridium Difficile has been recirculated to all clinical areas within the PCSM CPG and a copy is attached for ease of reference (please see number 7 attached to the action plan). Mandatory training is in place for all staff members on an annual basis. In recent months, the Governance Team in PCSM East have undertaken a “Train the Trainer” programme with the Infection Control Team and are assisting in the training of staff at ward level for times when staff cannot be released from the ward area to attend training sessions. The training which is delivered through the mandatory presentation covers the management of suspected and confirmed cases of Clostridium Difficile and the process of obtaining samples for testing. As detailed in the attached action plan, this incident has been shared across the PCSM CPG on all sites within Betsi Cadwaladr University Health Board (BCUHB) i.e. Wrexham Maelor Hospital, Glan Clwyd Hospital and Ysbyty Gwynedd so as to ensure wide awareness and learning. Le, GIG Bwrdd lechyd Prifysgol Betsi Cadwaladr 74, 4 University Health Board | shall now address the actions taken by the Infection Control and Prevention Team (ICPT). In addition to actions taken by the CPG, as detailed above, action is being taken by the ICPT to cover all sites in BCUHB to mitigate against similar incidents in the future. The Infection Prevention Education Programme within BCUHB was reviewed so as to ensure that education is provided to staff on all key issues. The revised programme includes education on management of patients who present with diarrhoea and the need to ensure specimens are sent to the laboratory. This came into being in January 2014. As part of actions being introduced to reduce the number of cases of Clostridium Difficile infection, a communications and awareness campaign was introduced in December 2013 which is aimed at all staff. This reinforces key standard required to prevent Clostridium Difficile infection and all the actions that must be taken immediately a patient develops diarrhoea, including obtaining a specimen and sending it for analysis. A plan to ensure that key standards for the prevention and management of Clostridium Difficile infection are highly visible and clearly understood is in the final stages of development. This work includes the use of key indicators in all wards when a case occurs. As a consequence of this, there will be an increase in the monitoring frequency of key standards and specifically includes a check to ensure that specimens are sent rapidly once diarrhoea occurs. The standards sheet is currently being finalised but a copy of the current version is attached (11) with RAG — red, amber, green status — ratings included as an example. An unannounced spot check was performed across all adult wards in Wrexham Maelor between 1° and 7" November 2013 to identify patients with diarrhoea and cross check this information with stool samples received in the laboratory. Of the 456 patients reviewed, a total of 17 had diarrhoea and samples from 14 of the 17 had been sent to the laboratory for analysis. The Infection Prevention Nurses provided on the spot education to staff, reinforcing the need for samples to be taken in the 3 cases where a sample had not been sent. A copy of the spot check summary is attached (12). This concludes the actions that have been taken to address the issues raised in your Regulation 28 report and | hope that you feel they have been addressed adequately. However, please do not hesitate to contact me if you require any additional information or if | can be of further assistance. Yours sincerely ANGELA HOPKINS Executive Director of Nursing on behalf of the Acting Chief Executive
Mersey Care INHS| NHS Trust Chief Executive's Office 14th March 2014 Trust Headquarters No. 8 Princes Parade Princes Dock St. Nicholas Place LIVERPOOL L3 1DL Telephone Number: 0151-285 2237 Fax Number: 0151- 285 2346 PRIVATE & CONFIDENTIAL Mr André Rebello ae Coroner's Court RECEIVED St George’s Hall St George’s Place Liverpool L1 1JJ Q H. M. CORONER Dear Mr Rebello, Thank you for raising your concerns about the fact that a Trust Policy had not been updated for some time and therefore was not representative of current practice. | can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that they reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place, 117 are now in date. Three policies are subject to a fundamental review; this process will be completed by 31°* March 2014. Between November 2013 and 12” February 2014, 50 policies have been reviewed and updated. | can confirm that the policy that provided you with concern at the Inquest on aac October 2013 was one of the first to be reviewed and updated. If | can provide any further information, please do not hesitate to contact me at the above address. Yours sincerely i Le | Joe Rafferty Chief Executive Chairman: Beatrice Fraenkel Chief Executive: Joe Rafferty
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