Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0376, written 16 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2013 |
|---|---|
| Reference | 2013-0376 |
| Deceased | Elsie May Treece |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| 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: Mrs Helen Ashley, Chief Executive, Queen’s Hospital, Burton Upon Trent CORONER | am Mr Andrew Haigh Senior Coroner for the Coroner area of Staffordshire South. 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 5 August 2013 | commenced an investigation into the death of Elsie May Treece aged 95. The investigation concluded at the end of the Inquest on 11 December 2013. The conclusion of the Inquest was accidental death. CIRCUMSTANCES OF THE DEATH On 18 July 2013 Mrs Treece had a fall in the care home where she lived, attended Queen's Hospital in Burton and was returned home. On 24 July she had another fall and this time was admitted to Queen's Hospital with a broken arm and an inoperable bleed to her brain. The head injury caused her death at the hospital on 2 August. 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) | received information from the family that on the afternoon of the 26 July 2013, following difficulties in moving Mrs Treece, for a while hospital staff left one of Mrs Treece’s daughters (aged 70) supporting her mother. One of them then returned with a blue lifting bag with handles but she was not properly supported and_fell back heavily on the bed with some force. Investigation has been carried out by HR the Ward 6 manager and | received a report which indicates there is no record of any such incident either in paper records, electronic records or from speaking to staff on duty. | did not investigate this incident fully because on balance it is unlikely to have been significant so far as the death is concerned. However the view | took on the evidence | did hear was that there had been an incident which should have been reported and may well not have been. j therefore write to you to enquire if staff need to be reminded or may need further training regarding the requirement to report inappropriate incidents even if no major harm seems to come to the patient involved. (2) While writing to you perhaps you could also find out for me the reasons why Mrs Treece did not have a CT scan of her head following the attendance on the 18 July 2013. This is not strictly a matter for this formal report but an answer would be appreciated. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 10 February 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. IL. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coro wing Interested Persons: (— daughter of Mrs Treece, — Legal Services Manager, Queen’s Hospital and — Manager, St Mary's Mount Residential Home. | have also sent it to Mr Derek Winter — HM Senior Coroner for the City of Sunderland and the Care Quality Commission who may find it useful or of interest. | 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. 16 December 2013 An I My Andrew A Haigh HM Senior Coroner Staffordshire (South)
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.
IAT - 13 Burton Hospitals NHS| NHS Foundation Trust Our Ref: HA/CS/ELS | Queen's Hospital Belvedere Road 31 January 2014 Burton Upon Trent 5 Staffordshire PRIVATE & CONFIDENTIAL Hy : DE13 ORB Mr A Haigh HM Senior Coroner Telephone: Coroner’s Office No. 1 Staffordshire Place Stafford $T16 2LP Dear Mr Haigh Re: Elsie May TREECE (Deceased) In response to the HM Coroner's Prevention of Future Death Report received by the Trust following the inquest of Elsie May Treece [B332952]. In relation to incident reporting, | can confirm that training has always been provided for staff in relation to the reporting of incidents. This training has been delivered by the Clinical Risk Team in collaboration with the Learning and Development Team. Registers of attendance are collated by the Learning and Development Team and entered against the annual training requirements for each staff member and uploaded onto the ESR system. Currently training is provided at Trust induction days, mandatory update training days, online training and ad hoc sessions in ward and department areas and provided for medical staff in different forum. Ad hoc training is provided as requested, and in light of this request for information from HM Coroner, we have arranged to provide additional training and support for Ward 6. More recently, we have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting and the feedback mechanisms which occur. Whilst it has been acknowledged that there was a period of downtime for the HISS computer system which occurred during the time of Mrs Treece’s admission, contingency plans were put in place which instigated the use of paper based documentation, and including paper based incident forms. Those paper incident forms received during and following the downtime were manually entered into the electronic system. With regard to point 2 of concern, as sons why Mrs Treece did not have a CT scan. Please find attached letter from outlining the reasons why a CT scan was not appropriate. Yours sincerely be A Helen Ashley Chief Executive: Att. WKZ025A ° Burton Hospitals INHS| NHS Foundation Trust Queen’s Hospital Belvedere Road Burton upon Trent Staffordshire DE13 ORB Our ref JAC/EG 23 January 2014 Legal Services Manager Queen's Hospital Dear Bridget Re: Elsie May Treece DoB: 2/6/1918 eeu puget ee sweet Mr Haigh has asked the Trust to look at the case of Mrs Elsie Treece who attended the Emergency Department on 18 July 2013 at 0317hrs. His specific question was to find out why Mrs Treece did not have a CT scan on that day. She was seen by a Foundation Year 2 Doctor at 0400hrs, after having routine triage, which showed that she was alert with normal observations. The Doctor who assessed her noted that she was suffering from a head injury, following a fall from her bed, where she landed on the floor. She sustained a laceration to the right forehead, without any evidence of loss of consciousness, vomiting or reduction in her normal conscious level. He also noted that she was not on Warfarin and was alert and comfortable on examination. ! have also looked at the West Midlands Ambulance Service documentation regarding her transfer to the Emergency Department and again, this corroborates the Doctor's notes where there was no evidence of loss of consciousness and also she was alert with a normal conscious level. Her symptoms and signs were not consistent with a significant head injury and therefore we would not have proceeded to do a CT scan as per NICE head injury guidance. There was no indication to carry out a CT scan at the time. Many thanks Yours sincerely scp In —— Medicine
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