Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0286, written 4 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2013 |
|---|---|
| Reference | 2013-0286 |
| Deceased | Susan Jill Hammond |
| Coroner | Stuart Fisher |
| Coroner area | Lincolnshire (Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 THIS REPORT IS BEING SENT TO: 1. Chief Executive, United Lincolnshire Hospital Trust, Lincoln County Hospital, Greetwell Road, Lincoln, LN2 5QY CORONER | am Stuart P G Fisher, Senior Coroner for the Coroner area of Central Lincolnshire, Lindum House, 10 Queen Street, Spilsby, Lincoln, Lincolnshire, PE23 5JE. 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. INVESTIGATION and INQUEST On 3 July 2009 | commenced an investigation into the death of Susan Jill Hammond aged 65 years. The investigation concluded at the end of the inquest on 30 October 2013. The cause of death was Anaphylactic reaction to the administration of intravenous augmentin. A narrative conclusion was given Mrs Hammond suffered a known allergy to penicillin despite this on 3 July 2009 a doctor prescribed augmentin (which is a penicillin based drug). This was administered to Mrs Hammond by an experienced nurse. A few minutes later Mrs Hammond suffered a cardiac arrest and despite attempts to resuscitate her she died at 0410 hours on 3 July 2009. CIRCUMSTANCES OF THE DEATH In both 1992 and 2002 Mrs Hammond had been administered penicillin and had suffered Anaphylactic reactions on both occasions. Prior to her death Mrs Hammond was living in a nursing home. She became ill and was admitted to the Accident and Emergency department of Lincoln County Hospital on 2 July 2009. Despite the fact that there were a considerable number of warnings on the documents sent by the nursing home, documents within the hospital and the fact that Mrs Hammond was wearing a red allergy warning bracelet she was administered augmentin (being a penicillin based drug) she suffered a cardiac arrest and despite attempts to resuscitate her she died. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Although there were written warnings of Mrs Hammond's allergy on hospital documentation they appear not to be have been noticed by the nurse who administered augmentin. In an effort to highlight the fact that a patient has an allergy | feel that there needs to be a much clearer indication on the file that the patient has such an allergy. At the inquest, it was suggested that a different coloured file should be used for any patient who has an allergy. Alternatively, a large sticker on the front of the file warning of the allergy would assist. (2) It appears that when Mrs Hammond transferred from the A&E unit to the EAU she was accompanied by a nurse who had little knowledge of Mrs Hammond's condition. As a consequence no discussion took place at the handover regarding the nature of Mrs Hammond's allergy to penicillin. It is felt that if the nurse who had cared for Mrs Hammond in the A&E department had personally accompanied her to the EAU this would have enabled a more productive handover and would have given an opportunity for discussion regarding the allergy. Although | appreciate there may be practical difficulties | would suggest that in future the nurse who has provided care for the patient in A&E should always accompany the patient to the EAU department in order that constructive handover can take place. (3) Your representative at the inquest hearing was not clear as to whether the doctor involved in this case was going to be referred to the General Medical Council and the nurse who administered Augmentin was going to be referred to the Nursing & Midwifery Council it was agreed that he would inform me of this within 14 days of conclusion of the inquest. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 25 December. |, 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 Solicitors representing the family, and [and nurse lam 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 thi [DATE] 4) ‘1 ]13 [SIGNED BY CORONER]
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.
Swe United Lincolnshire Hospitals [779 : NHS Trust sage : Trust Headquarters PRIVATE & CONFIDENTIAL Lincoln County Hospital Mr SPG Fisher Greetwell Road HM Senior Coroner for Central Lincolnshire LND aAx Lindum House 10 Queen Street Spilsby Tel: 01522 512512 Lincolnshire PE23 5JE aE _— = " 23% December 2013 Dear Mr Fisher Thank you for your letter dated 4" November 2013 issued under Regulation 28: Report to prevent future deaths, in relation to the risks you identified through the Inquest touching the death of the late Susan Jill Hammond. | write to provide assurance that we have taken steps to resolve the issues highlighted in your letter. 1) Allergy warnings Prior to Mrs Hammond's death in 2009 the control measures in place were: e Prescription chart “drug sensitivities” box to be completed with any allergies and referred to when prescribing, dispensing or administering medications. Red allergy band to be used for any patients with a medication or product allergy. Medicines management policy, setting out roles and responsibilities. Admission proforma multidisciplinary document allergy question. A&E records contain an allergy section which is prepopulated from the Patient Administration system. The Health Record contains an alert page for allergies to be documented and older records had this information on the front cover. e Alerts to the risks of penicillin allergy were contained within the antibiotic guidelines, in both short form and full versions. Following the incident additional action was taken. These were: e The revision of antibiotic guidelines to increase awareness of risks of penicillin allergy and with associated drugs. e The development of a traffic light based risk recognition system for penicillin allergic patients e Prescription chart also includes a prompt statement that all pages of the chart must be reviewed when prescribing/administering any medicine. e A patient safety campaign highlighting the allergy risk and the traffic light based system to manage penicillin allergy safely, targeting all doctors, nurses and pharmacists. e Antibiotic short guide pocket cards with penicillin safety alert issued to medical and nursing staff to raise awareness. e Competency assessment of nurses administering medications. e Formalised medicines reconciliation process which will support review of medications and allergies. Chairman: Paul Richardson Chief Executive: Jane Lewington Osage at MBog, Suess MINDFUL = Vs EMPLOYER e Modification of the prescription chart to state “Drug allergies and sensitivities” in a red “ coloured title, with more space to list drugs and the effects, with the source of information and completion signature, name and date. Allergy section on prescription chart before: 2) The handover of care from A&E to MEAU is now based on a handover tool, called SBAR. This is an acronym for Situation, Background Assessment and Recommendation and allows for a structured handover to take place. This approach brings consistency in communicating key points of information. Within the background section is a prompt sheet for highlighting allergies. SBAR has been found to improve communications between members in different clinical areas ie A&E Vs wards. 3) a: :: been referred to the General Medical Council. 4) The Trust's Interim Director of Nursing has reviewed the professional conduct and implications in relation to the registered nurse involved. This included reviewing the available information from the time of the event in 2009. At the time of the event in 2009, the nurse's practice and competence in administration of Rs : ; , Se ef’ s MINDFUL Chairman: Paul Richardson EVV RY Atel Chief Executive: Jane Lewington PAG medicine was reviewed and a training update undertaken. Since that time, the nurse's practice has been without any further incident. Following the inquest, the nurse's practice was further considered and taking into account the impact of the inquest on the nurse she was restricted from involvement in medicines administration for a short period of time to protect both patients and herself. She has since received further training and competence assessment, which she passed without concern. With reference to your query about referral to professional regulators, the Interim Director of Nursing can confirm that she has discussed this case in detail with Nursing and Midwifery Council. This discussion included reference to actions already taken by the Trust. The discussion concluded with the Council's confirmation that they will review the case. If you require any further information, | would be happy to liaise with you directly. Yours sincerely Medical Director (GMC No 2837444) Chairman: Paul Richardson § es MINDFUL Chief Executive: Jane Lewington PAG EMPLOYER
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