Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0317, written 27 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 | 27 Nov 2013 |
|---|---|
| Reference | 2013-0317 |
| Deceased | Edna Elsie Mary Eden |
| Coroner | Peter James Bedford |
| Coroner area | Berkshire |
| 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.
ANNEX A 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: Philippa Slinger, Chief Executive of Wexham Park Hospital Trust 1 CORONER I am Peter James Bedford, Senior Coroner for the coroner area of Berkshire 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 17th August 2011 I commenced an investigation into the death of Edna Elsie Mary Eden, then aged eighty eight years. The investigation concluded at the end of the inquest on 20th November 2013. The conclusion of the inquest was a narrative verdict returned by the Jury and I attach a copy to this Report. The medical cause of death was Myocardial Infarction due to Coronary Atheroma on a background of Bronchopneumonia. 4 CIRCUMSTANCES OF THE DEATH (1) Mrs Eden was generally of good health for her age and had been living independently. On Friday 12th August 2011 she complained to her niece that she was feeling a bit poorly. She was seen by a GP and prescribed antibiotics for a chest infection but, following a further review the next day, a different GP admitted her to your Hospital being described as non-specifically unwell. The letter that accompanied her included the words “some right sided chest pain.” (2) At Wexham Park Hospital, Mrs Eden remained in A&E for five hours under the care of nursing staff. A Doctor appears to have authorised an ECG and blood tests without actually seeing the patient. There was a signature on the ECG printout but the identity of the person, presumed to be a Doctor, has not been ascertained. The ECG is described as abnormal but was not escalated to any other Clinician. The blood tests appear not to have been reviewed by any Clinician. (3) Having arrived at A&E at 14.34 hours on 12th August 2011, Mrs Eden was transferred to the AMU at 19.45 hours. A nursing observation chart shows observations being documented at 15.10, 17.43 and 18.10 hours in A&E and 20.00 and 21.58 hours in AMU. There is a reference in the nursing notes of observations being done at 23.25 hours but these were not recorded on the chart. The chart included an EDOD score which, as accepted in evidence, was wrongly scored at three but should have been scored at four. This should have triggered a Doctor review within thirty minutes but this was not done. 1 (4) The nurse responsible for Mrs Eden on AMU documented four attempts to contact a Doctor by bleep, all without success or response. The evidence was that Doctors were aware of Mrs Eden needing to be seen but it was a very busy weekend for patients and priority was being given to other more urgent patients. (5) The Doctors who made the decision not to prioritise Mrs Eden were not aware of the abnormal ECG or blood results. (6) Mrs Eden was not finally seen by a Doctor until 17.00 hours, some fourteen and a half hours after her arrival at the Hospital. Within minutes of being seen, she arrested and could not be revived. (7) An independent expert Consultant Cardiologist gave evidence that Mrs Eden’s heart was sufficiently diseased that she would have died within hours in any event. However, from the evidence, it was recognised that there were missed opportunities to intervene with earlier care that may have prolonged her life for a number of hours which would have allowed Mrs Eden and/or her family to say goodbye. 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) Mrs Eden was admitted having been prescribed antibiotics by her GP. She was not provided with further antibiotic cover pending being seen by a Doctor and that was unduly delayed meaning that she went fourteen and a half hours without her prescribed medication. (2) The nursing observation chart suggested infrequent observations for a patient who had not yet been clerked by a Doctor. The EDOD score was wrongly calculated which meant an escalation of Doctor review was not carried out. (3) Nursing staff were not able to make contact with Doctors to review Mrs Eden. When this continued, the problem was not escalated to more senior staff. (4) Clinicians were taking decisions over priority of seeing patients based only on a very vague description of Mrs Eden’s condition. Information at handovers appeared very limited. (5) Junior staff on a very busy shift appeared reluctant, or ignorant of the procedures, to escalate concerns to more senior staff to address a significant backlog that had developed. (6) An elderly patient who was admitted with a covering letter describing recent chest pain was not seen by a Doctor for a total of fourteen and a half hours. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. about an action plan that had been At the Inquest, evidence was given by Doctor put in place. However, there were clearly outstanding issues and matters that had still not yet been addressed which is why I bring all the issues arising at the Inquest to your 2 attention. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th January 2014. 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. 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 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. 9 27th November 2013 Peter J. Bedford H.M. Senior Coroner for Berkshire 3
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.
Heatherwood and Wexham Park Hospitals fift- NHS Foundation Trust Medical Director's Office Direct Line Telephone Number: xxx Fax Number: xxx Our Ref: BC/RL/eh/EdenE-25 Wexham Park Hospital Wexham Street Slough Berkshire SL2 4HL Your Ref: PJB Eden Reg 28 Switchboard: 01 753 633000 HAND DELIVERED 20 January 2014 Mr Peter Bedford HM Coroner Berkshire Yeomanry House 13'1 Castle Hill Reading Berkshire RG1 7TA Dear Mr Bedford Re: Inquest into the death of Edna Elsie Eden - v - Response to Requlation 28 Report to Prevent Future Deaths Thank you for your letter dated 27 November 2013. Firstly I would like to thank you for bringing to my attention the matters raised in the Regulation 28 Report to Prevent Future Deaths. I was sorry to learn about the problems that the late Mrs Eden encountered when admitted to our Trust. As evidenced in your inquiry and our own internal investigation it is clear to me that we failed to deliver the high standards of care that Mrs Eden was entitled to expect. Whilst I have no doubt that everyone involved in her case thought they were doing the best for her at the time, it is clear that mistakes were made and lessons will be learnt. I have grouped my response under three headings set out below i.e. action taken before inquest, immediate action taken after the inquest and action to be taken. Action taken before the inquest As you know the Trust had already taken some action following its own internal investigation. You were informed of these during the inquest hearing therefore I will not rehearse them here again. However in addition I wanted to specifically point out that a new Policy i.e. TPP 231 (enclosed) which focuses on the Management of the Deteriorating Adult Patient was introduced in August 2013. This Policy has introduced a new requirement for ensuring that the EDOD score calculation is verified by another member of staff to reduce inaccuracies as was in this case. An audit capturing the number of correctly calculated EDOD scores was carried out in July 2013 and the results of this audit highlighted very good compliance; with all standards exceeding the 90% mark and as well as showing that every patient with an increased EDOD score had the algorithm followed appropriately. $"1 \.^.d - 2 - Peter Bedford HM Coroner, Berkshire Our Ref: BRC/RL/eh/EdenE-25 20 January 2014 ln addition TPP 231 has strengthened the use of Situation Background Assessment Recommendation tool used when notifying Doctors over the phone or in person of a patient for review. The tool ensures important information is conveyed in order to allow the Doctor to paint a picture of the patient's condition and prioritise review as necessary. (SBAR) tool. This is a communication lmmediate action taken after the inquest The new MSS system was introduced in the Emergency Department on 14 January 2014 and has an added function of calculating the EDOD score electronically thereby reducing the possibility of wrong calculations. All referrals to the Hospital pass through the Emergency Department. On 14 January 2014 the Trust introduced a new Procedure for dealing with referrals to the hospital. Although some aspects of this new procedure are undenrvay the electronic section is expected to go live in six weeks' time. The electronic system will ensure that instead of using the bleep system to notify inpatient teams that there is a patient in the Emergency Department or that there is a GP referred patient who needs to be reviewed a message will be sent via Smaftphone. The Specialist Registrar receives an e-mail alert and then allocates the job within the team. On receiving the e-mail it will be the inpatient team's goal to see the patient within one hour of referral thereby ensuring no delays. This system will eradicated issues previously identified at times with bleeps with regards to not having an audit trail. This system will also provide assurance to staff that when a message is sent to the Specialist Registrar it has been received and will therefore be acted upon. Action to be taken in the future The Trust has plans to introduce a 24 hours a day Central Hub system and the timescales for actions are stated in the enclosed action plan. lt is envisaged the Hub will be located at Wexham Park Hospital and be equipped with lT systems and run by senior managers who will be responsible for ensuring the following: o Tracking of all patients throughout their hospital stay; o Manage all bleeps; o Manage all GP and inpatient referrals; o Review the workload of clinicians; o Obtain formal handover throughout the Trust, 3 times a day; o Allocate jobs to Doctors; o Review any uncompleted o Redistribute work where a team is overloaded; o Authorise employment of extra staff depending on workload; o Escalate to the Duty Manager and On-Call Director as necessary. tasks and reallocate as necessary; Some of the work with regards to a Central Hub is already undenrvay in that the location has been identified and at least six senior managers have been recruited so far with more to follow. i Peter Bedford HM Coroner, Berkshire Our Ref: BRC/RL/eh/EdenE-25 20 January 2014 - 3 - It is my view that the Central Hub will help reduce the recurrence of the root causes identified in Mrs Eden's care namely: o no doctor review due to lack of appropriate patient tracking system; o no response to bleeps as tracking junior doctors caseload monitored centrally; o better administration inadequate handover; o regarding GP referrals; I realise that these changes cannot change what has happened to Mrs Eden or put everything right but I hope the plans set out in this letter will reduce the likelihood of a similar n ce again thank you for bringing this matter to my attention. Medical Director
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