Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0007, written 7 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jan 2014 |
|---|---|
| Reference | 2014-0007 |
| Deceased | Grace Mary Bates |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barnet and Chase Farm Hospitals NHS Trust |
| 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.
i, North London Coroners Court Her Majesty's Coroner for the 29 Wood Steel Northern District of Greater London Barnet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Barnet and Chase Farm Hospitals NHS Trust Wellhouse Lane, Barnet, Herts ENS5 3DJ 2. Copy to:- Department of Health Department of Health Richmond House 79 Whitehall London SW1A 2NS 1 | CORONER ! am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 24 day of April 2013 | opened an investigation into the death of Grace Mary Bates, aged 93 years old. The investigation concluded at the end of the inquest on the 16" December 2013. The conclusion of the inquest was “ Grace Mary Bates died on the ai April 2013 in hospital as the result of complications from poorly managed diabetic episodes”, the medical cause of death was complications of diabetes mellitus. 4 | CIRCUMSTANCES OF THE DEATH Mrs Bates presented to the On the 29" March 2013 having been referred by her own doctor having become unwell during the previous week. Mrs Bates was continued on her regime of medication for her diabetes. There was no specialist diabetic nurse available over the weekend (beginning on the 20" April 2013) and the management of Mrs Bates blood sugar levels was poor during this period. Mrs Bates died in hospital from the complications of poorly managed hypoglycaemic episodes on the 21" April 2013. Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 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) That should be a specialist diabetic nurse available over the weekend at the hospital. 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 Monday 7 April 2014, |, 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 members of the family. | 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. roner Andrew Walker Senior Coroner
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.
From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of H ealt h Richmond House 79 Whitehall London POCI_ 834309 SWIA 2NS Tel: 020 7210 3000 Mr Andrew Walker Mb-sofs@dh. gsi. gov.uk HM Senior Coroner Northern District of Greater London North London Coroners Court 29 Wood Street Barnet 44 CeO one ENS 4BE 1) Me Welb Thank you for your letter about the inquest into the death of Grace Mary Bates. On 21 April 2013, Mrs Bates died as the result of complications from poorly managed diabetic episodes following admission to Barnet Hospital. The medical cause of death was complications of diabetes mellitus. Your report summarised the circumstances regarding Mrs Bates’ death, noting in particular, the poor management of blood sugar levels and the absence of a specialist diabetic nurse over the weekend. All registered nurses (RNs) are accountable for and have skills in blood glucose monitoring. Their skills include monitoring blood glucose, recording findings, evaluating whether each reading falls within an expected range and taking the necessary action. This is the most elementary level of care. In more specialist areas, such as endocrinology wards, which may have a higher concentration of people with diabetes, it is usual for RNs to have developed their competence in titrating medicines in response to blood glucose readings. In this situation, the Trust should apply clinical governance mechanisms to enable this to take place safely and effectively. The National Institute for Health and Care Excellence (NICE) quality standard on diabetes states that people with diabetes admitted to hospital should be cared for by appropriately trained staff and be provided with access to a specialist diabetes team. These standards provide an authoritative definition of good quality care and should be used as a basis for best practice. Local organisations are best placed to assess the needs of their populations, and to commission and deliver high-quality, safe and comprehensive diabetes services; including appropriate nursing staff and I expect local healthcare organisations to do their utmost to deliver care against NICE standards as part of a general duty to ensure continuous improvement in quality. The wider issue of patient outcomes and weekend admissions has been recognised as a matter of national significance. NHS England has assessed the considerable evidence which has emerged over the last ten years, linking the reduced level of service provision at the weekend to poor outcomes for patients admitted to hospital as an emergency. The NHS Services Seven Days a Week Forum, established by the National Medical Director Sir Bruce Keogh, has developed ten clinical standards describing the standard of urgent and emergency care that all patients should expect to receive on every day of the week. Their delivery should reduce the risk of morbidity and mortality following weekend admission in a range of specialties including diabetes, and provide consistent NHS services, across all seven days of the week. The Forum has not attempted to specify the roles and grades of staff that should be present at weekends, except in the case of medical consultants where there is good evidence about the effect of absence of senior decision makers. The standards describe how quickly admitted patients should be seen and assessed on every day of the week by a suitable medical consultant, defined as ‘one who is familiar with the type of emergency presentations in the relevant specialty and is able to initiate a diagnostic and treatment plan’. The clinical standards are attached for your convenience and further information about the work of the forum can be found at http://www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/ NHS England’s ambition is for all the clinical standards to be adopted in every community in England by the end of 2016/17. With a number of our key strategic partners, we will use a range of incentives, rewards and sanctions, including the NHS Standard Contract, to support the change. I do hope that this information is helpful and I thank you for bringing this important issue to my attention. Yuu f mut, Ue we -_ JEREMY HUNT RECEIVED 13 FEB 2014
Barnet and Chase Farm Hospitals NHS | NHS Trust Barnet Hospital Wellhouse Lane Barnet Hertfordshire EN5 3DJ www.bcf.nhs.uk Mr Andrew Walker Tel: 0845 111 4000 Senior Coroner North London Coroners Court 29 Wood Street Barnet EN5 4BE 7 April 2014 Dear Sir Grace Bates, Deceased Regulation 28 Report to prevent future deaths | am responding to your concerns that there should be a specialist diabetic nurse available over the weekend at the hospital. Our Head of Diabetes & Endocrinology; Business Manager for Diabetes and our Lead Diabetes Nurse submitted a business case for the approval for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week. The business case has been approved and an appointment is awaited. Yours faithfully, whe Medical Director Barnet and Chase Farm Hospitals are SMOKE FREE - smoking is NOT PERMITTED on any trust site. Chairman: Baroness Wall of New Barnet Associated University Trust Interim Chief Executive: Dr Tim Peachey ssoci WZZ 426
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