Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0362, written 5 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 | 5 Nov 2013 |
|---|---|
| Reference | 2013-0362 |
| Deceased | Ethel Cross |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Lancashire Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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,
Blackpool Teaching Hospitals NHS Foundation Trust
CORONER
fam Alan Wilson, Senior Coroner, for the area of Blackpool & Fyide
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 224 April 2013 an investigation commenced into the death of Ethel Cross, aged 91
years. The investigation concluded at the end of the inquest on 22” October 2013.
The record of the inquest confirmed as follows:
The Medical cause of death was
la Fat Embolism
Ib Fractured Neck of Femur
ll Chronic Heart Failure and Coronary Heart Disease
The conclusion of the Coroner as to the death was
Accidental Death
4 | CIRCUMSTANCES OF THE DEATH
Ethel Cross had a history of falls.
On 12" April 2013 at 0630 hours who had a history of falls, fell whilst returning from the
bathroom on ward 4 at the Clifton Hospital. She sat on a chair for a rest. The chair
slipped. She suffered a fracture of her neck of femur. Initially, she was not noted to be in
pain. She later did complain of pain and was therefore taken to Blackpool Victoria
Hospital.
She died on the 13" April 2013.
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. —
At the conclusion of the inquest, | indicated to the Properly Interested Persons that |
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
During the Inquiry, | received evidence that chairs utilised by staff which have wheels
attached to them had been present on ward 4 and that Ethel Cross had sat on one of
these chairs which slipped and she suffered a fracture. | heard evidence that these
chairs have been removed from two wards — including ward 4 - on which elderly patients
at significant risk of falls may be cared for. | am concerned that such chairs may |
continue to be present on other wards within the Trust where such patients may have
access to them and similar incidents may occur.
| During the course of the evidence | heard that although at high risk of falls, and
someone who would need one to one assistance from staff when mobilising, Ethel Cross
was not provided with an alarm that in the event of her moving when staff are not nearby
| could alert members of the medical staff to such movement allowing the staff to attend to
her. All such alarms on the ward were in use and such alarms are rarely not deployed.
Having concluded this inquest, | now write to the Trust to confirm that in my view the
Trust should take action because:
e the presence of such chairs - with wheels attached — in an area frequented by
elderly patients may lead to further such fatalities should elderly patients
access them
® patients who are at high risk of falls may try to mobilise themselves
_ unsupported when staff are busy elsewhere on the ward with other patients and
all of the available alarms are in use.
{ would therefore be obliged if the Trust would write to me in due course to confirm what
steps if any the Trust proposes to take to address these two areas of concern.
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 2m 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.
| COPIES and PUBLICATION
| | have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
The family of Ethel Cross
The Coroners 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 compiete 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 1
Alan Wilson
Senior Coroner for the area of Blackpool & Fylde
response, about the release or the publication of your response by the Chief Coroner. ]
Dated: 5" November 2013 |
i
Blackpool Teaching Hospitals
NHS Foundation Trust
Trust Headquarters
Biackpoot Victoria Hospital
Whinney Heys Road
Blackpool
Lancashire
FY3 8NR
Telephone: 01253 655568
Fax: 01253 303843
Your Ref: AVH/KAH
Our Ref: DG/Cross
Date: 314° December 2013
Mr A Wilson
HM Coroner
Blackpool & Fylde District
Municipal Buildings
PO Box 1066
Corporation Street
Blackpool
FY1 1GB
Dear Mr Wilson
Re Ethel Cross
Formerly of 29 East Cliffe Lytham St Annes FY8 5DX
Date of Birth -8" December 1921
Date of Death13th April 2013
| am writing to respond to your Regulation 28 report to prevent future deaths made
pursuant to the powers given to you under paragraph 7, Schedule 5 of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.
At the end of the Inquest into the death of Ethel Cross, which concluded on the 22™
October 2013, you raised the following concerns:-
1. The presence of chairs with wheels attached in an area frequented by elderly
patients may lead to further such fatalities should elderly patients access them.
2. Patients who are at high risk of falls may try to mobilse themselves unsupported
when staff are busy elsewhere on the Ward with other patients and all of the
available alarms are in use.
RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROWS CARE
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are
actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may
discuss current clinical trials with you.
The
S®, information
@ V Standard
Chairman: Mr ian Johnson M.A., LL.M.
Chief Executive: Mr Gary Doherty
ee, &
Ev Vv fm
= x
. &
rsa
Blackpool Teaching Hospitals NHS
NHS Foundation Trisst
Subsequent to receipt of the Regulation 28 report a meeting took place at the Trust with
the following members of staff:-
Marie Thompson - Director of Nursing & Quality
Simone Anderton ~ Associate Director of Nursing Unscheduled Care Division
Tracy Burrell -Assistant Director of Nursing Patient Safety
Debra Mathlouthi — Health & Safety Manager
PONS
As you are aware following the initial incident on Ward 4 at Clifton Rehabilitation Hospital
all the wheeled chairs were removed from that Ward and Ward 1 at Clifton Rehabilitation
Hospital.
Debra Mathlouthi carried out a risk assessment in respect of the chairs and the falls
prevention monitors, a copy of her findings are attached. You will see the
recommendations noted therein.
The potential implementation and viability of those recommendations were then discussed
with Simone Anderton and Tracy Burrell and the following action plan has been
implemented:-
1. Identify the nurse stations within the Trust which pose a high risk to patients who
may access wheeled chairs.
2. The following areas have been identified as high risk areas, i.e due to the
positioning of the nurse station, patients have easier access to wheeled chairs
within the nurse station area:
e Wards 1, 2, 3 & 4 at Clifton Rehabilitation Hospital site.
e Ward C at the Blackpool Victoria Hospital site.
All wheeled chairs have been moved from nurse stations in these areas.
3. In respect of patient falls the Trust has developed a Falls Steering Group which
monitor, assess and develop, through educating staff and identifying trends and
individual patient risk, systems and working practices to reduce the risk and
incidents of falls within the Trust.
The Trust, as part of the staffing review completed in July 2012, has invested £1.3
million pounds into staffing levels which has supported the concept of Bay based
nursing within areas of high risk.
The concept of Bay based nursing utilises the allocation of staff per shift to work in
the Ward Bays with attached side rooms, rather than across two teams split over
the Ward.
The aim of Bay based nursing is to increase visibility and the presence of the
nursing staff within patient areas, which has proved to show a reduction in the
incidents of patient falls and harm.
Blackpool Teaching Hospitals [
NHS Foundation Trust
The Trust has also incorporated a “Tag” system within the Bay nursing concept
which means the Bay is never left unattended, as when one nurse leaves she is
tagged by the incoming nurse.
However, that said, | would note that, sadly, it is a fact of hospital life that patients,
particularly elderly patients and patients with multiple co-morbidities, do fall. The falls
monitors which are attached to patients can, and are, on a regular basis, removed by
patients, which negates the purpose. ;
itis an ongoing task for the Trust to reduce the level of falls.
The information below is a summary of the Trust Falls Steering Group.
e There has been targeted support and training given to wards within both the
Scheduled and Unscheduled Divisions to improve the staffs understanding in relation
to bone health and fails risks this included education around the falls risk assessment
and the formulation of a care plan for patients at risk of falling.
e Introduction of movement sensors in all the clinical divisions, both on the acute wards
and in the community hospitals, for patients who are identified to be at high risk of
falling. The sensors are discreet and can be placed either under the mattress of the
bed, or on the chair if the patient is sitting out of their bed. The sensors alert the ward
nurses via a pager system if a patient attempts to get out of bed or move from the chair
unaided. The sensors have already helped prevent potential injury to patients as the
nursing staff have been alerted swiftly and assistance given.
e Low beds have been trialed and the trust has introduced these (7 in total) to prevent
falls for those patients at higher risk.
e A footwear trial has been completed and we have changed and standardised the
products used across the Trust.
e We have developed a slipper exchange scheme in the care of the older adult wards.
e Greater cross boundary working with colleagues working in the community.
e The Trust Falls Steering Group has been re-invigorated and is now multi-disciplinary
and includes voluntary agencies.
e A falls prevention workbook has been developed and rolled out across the organisation
to improve staff education, this is currently being reviewed following feedback to
simplify it for staff.
e Falls prevention leaflets have been developed to improve patient education.
e Ward level standards have been introduced in Scheduled Care.
in 2011/12 there were 2205 falls with harm compared with 2216 in 2012/13. There were
35 patients who experienced a fall that resulted in a moderate/serious harm. This is a
15% reduction on the number of patients who experienced the same harm in 2011/12. In
the rolling twelve months to November 2013 there have been 1885 falis with harm. In
year, in the 8 months to November 2013 there have been 1129 falls with harm and at this
Blackpool Teaching Hospitals NHS}
NES Foundation Trust
rate we would expect to see no more than 1694 falls with harm for 2013/14, a reduction on
last year’s total of 30%. Measures have been put into place as outlined above and it is
anticipated that the Trust will continue to see a downward trend in serious falls.
Total Falls 12 month comparison
‘Siioulscncinsonesiinb elimina nested aeleini testi aRepn G/L otmsRafeaaatetieeethahntomsiansnonicnboveccisaniineits
SPC Chart: Tetal Falés
8
8
8
Number of falls
8
%
ae ys ee
MONK NS NS OD :
POLS EE ES EES ES $
oF FES CK STS SS ¥
2 2 2
woofs ni ICR om VETERE me Trend
Blackpool Teaching Hospitals INAS!
NHS Foundation Trust
SPC Chart: Serious & Above Falls
18... ee _
Fee ee Ses
mada BNO DBI omg OR apie BNGE HO mane Feendd
We hope the above is a satisfactory response to the Coroners Regulation 28 report.
Please don’t hesitate to contact the Trust for further information if required.
Yours sincerely ,
Wtnous is
Marie Thompson
Director of Nursing and Quality
All such alarms on the ward were in use and such alarms are rarely not
deployed..(please see image below)
A Fall Prevention Monitor easily moves from bed to chair, eliminating the need
to have multiple monitors. The pull string functions work independently
making a versatile fall alarm monitor.
The Pull String feature of the Fall Prevention Monitor works by simply clipping
the garment clip onto the patients clothing and attaching the monitor to bed or
chair.. If the cord is pulled away from the monitor the alarm is triggered,
alerting staff.
Recommendations
1. All chairs with castor wheels to be removed from patient areas where
there is a foreseeable risk of patient falls.
2. Static chairs to be put in place preferably with arms which would help
stabilise a patient in the event that they pulled out the chair to sit
down.
Or
3. Chairs with castor wheels on can be replaced with locking/breaking
castor wheels however, this will be financial implications to the Trust.
4. Chairs with castor wheels are used in clinical / nursing areas across
the Trust. A full audit of all clinical areas to be carried out to identify
the high risk areas to make the recommended changes.
5. More fall monitors to be purchased to reduce the risk of patient falls.
Debra Mathlouthi
Health and Safety Manager
Incident number 89193 — Ethel Cress
Investigation / findings following Letter 28
Chairs utilised by staff which have castor wheels attached to them had been
present on ward 4 and patient E C had sat on one of these chairs which
slipped and she suffered a fracture. (please see image below)
The chair has been removed from ward 4 - on which eiderly patients at
significant risk of falls are cared for and replaced with a static chair tucked
under the nursing station when not being used. (please see image below)
The Coroner is concerned that such chairs may continue to be present on
other wards within the Trust where such patients may have access to them
and similar incidents may occur.
It has been identified that the chairs with castor wheels are used in
clinical / nursing areas across the Trust
Although at high risk of falls, and someone who would need one to one
assistance from staff when mobilising, E C was not provided with an alarm
that in the event of her moving when staff are not nearby could alert
members of the medical staff to such movement allowing the staff to attend to
her.
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,
Lancashire Care NHS Foundation Trust
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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 6th July 2010 an investigation commenced into the death of Roy Frank Fletcher,
aged 63 years. The investigation concluded at the end of the inquest heard on 12th and
19th December 2013.
The record of the inquest confirmed as follows:
The Medical cause of death was
Ia Hanging
The conclusion of the Coroner as to the death was Narrative conclusion as follows:
Roy Frank Fletcher had a long history of depression. On the 25th May 2010
he was admitted to the Conway Ward, and acute admission ward, at
Parkwood Hospital in Blackpool. He was agreeable to remaining there for
care and treatment.
Following an incident of self harm during a period of unescorted leave, a
decision was taken that he could only be allowed escorted leave.
At a Care Programme Approach Review on 6th July 2010 Roy handed to his
therapeutic team some hand written notes within which he had sought to
explain how he was feeling. Before the content of those notes had been fully
considered he decided to leave Parkwood. Later that day he exited the
Conway Ward through a door that had been left partially open. He made
his way to the main exit from the building. When another service user was
allowed to leave the reception area Roy took the opportunity to follow that
service user out of the building. It was not appreciated that Roy had no
1
permission to leave at that time.
Roy made his way to a local holiday park and at approximately 7.30 pm was
found deceased having taken his own life by hanging himself by use of a
rope as a ligature whilst the balance of his mind was disturbed.
4
CIRCUMSTANCES OF THE DEATH
See the contents of section 3 above.
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. –
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
During the Inquiry, I received written evidence by way of a post incident review
conducted by the Trust into the death of the Deceased. On 19th December 2013 I
received oral evidence from
on behalf of the Trust and who was
the author of the Post Incident Review. I am concerned that the review undertaken was
significantly lacking for the following reasons:
CCTV footage shows that at the relevant time the Deceased shows him
following another Service User out of the reception area at the hospital. It seems
no steps had been taken to speak to that Service User in order to establish if he
had been aware that he was a vehicle for the Deceased’s exit from hospital, and
if so on what basis.
Further, the oral evidence provided to the inquiry by
suggested that the review had not explored whether other service users had left
the relevant ward, or the reception area of the hospital in similar circumstances.
Having concluded this inquest, I now write to the Trust to confirm that in my view the
Trust should take action because:
When Post Incident Reviews are undertaken it is important that they are
thorough and comprehensive and that all of the relevant issues are explored
prior to recommendations being made arising from that review and the
organisation making recommendation for remedial action, if any, to be
undertaken.
If such reviews are lacking, there is a risk that an organisation may not
appreciate whether a problem is a persistent one, potentially helpful changes to
procedures may not be put in place and future deaths may occur which may
otherwise have been prevented.
I would therefore be obliged if the Trust would write to me in due course to confirm what
steps if any the Trust proposes to take to address these concerns.
2
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 17th February 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
The family of Roy Frank Fletcher
The Coroners Society
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.
8
9
Alan Wilson
Senior Coroner for the area of Blackpool & Fylde
Dated: 20th December 2013
3
See every Prevention of Future Deaths report matching Lancashire Care NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.