Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0043, written 30 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 | 30 Jan 2014 |
|---|---|
| Reference | 2014-0043 |
| Deceased | Leslie Pates |
| Coroner | John Pollard |
| Coroner area | Manchester 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Tameside NHS Foundation Trust Chief Executive, Tameside MBC 1 | CORONER lam John Pollard, senior coroner, for the coroner area of South Manchester 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 5" April 2013 | commenced an investigation into the death of Leslie Alfred Pates dob 21° February 1932. The investigation concluded on the 29" January 2014 and the conclusion was that he died from Natural Causes. The medical cause of death was 1a Sepsis 1b Pressure sore 1c Immobility/stroke 2 Vascular dementia, Chronic Obstructive Pulmonary Disease, Hypertension, Stroke. 4 | CIRCUMSTANCES OF THE DEATH On the 11" December 2012 he was admitted to Tameside General Hospital Medical Assessment Unit, later being placed on wards 42 and 43. He was eventually discharged home on the 22"° January 2013 against the wishes of his family. The Consultant heading up his care accepted that he did not see the patient prior to his discharge, that he had no grounds for saying that “the family were happy for him to go home” and that there was no reasonable analysis made by the hospital and others as to his fitness to return home. The social worker conceded that there had been no meeting with the family to discuss discharge (as should be the case), that matters “were not in place from a Social Services position” and that there had been no liaison between social services and the District Nurse teams. On the 27" January 2013 he had to be transferred from his home toa Nursing Home and by the 17" February 2013 his condition was so bad that he was re-admitted to Tameside General Hospital by 999 ambulance. A doctor at the hospital supplied an MCCD to the coroner which gave the cause of death on the 2" April 2013 as sepsis when | heard evidence from the consultant chest physician that he found the patient on the morning of the 2" April 2013 to be apyrexial with clean pressure sore. 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.There has been a complete breakdown in effective communication between the hospital and the family of the deceased. 2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. 5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place. 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. It is essential that full information is passed promptly to the GP practice of a patient being discharged. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30" March 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 namely SM 2uchtcr of the Deceased. | 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. 30 January 2014 John Pollard, HM Senior 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.
Tameside Hospital NHS) NHS Foundation Trust Tameside General Hospital Chief Executives Office Silver Springs Fountain Street Tameside General Hospital Ashton-Under-Lyne Ashton-Under-Lyne Tameside OLG ORW OL6 SRW Telephone: 0161 331 6000 Our Ref: KA/PW/AD/JB/Coroner Your Ref: JSP/KA/00911-2013 Date: 26 March 2014 Strictly Private & Confidential Mr JS Pollard Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG RESPONSE TO REGULATION 28 LETTER Dear Mr Pollard Thank you for your letter of the 30" January 2014 setting out your concerns under Regulations 28 of the Coroners (Investigations) Regulations 2013. On the 29" January 2014, you held an Inquest into the death of Leslie Alfred Pates who died on the 2™ April 2013. The medical cause of death was recorded as: 1(a) Sepsis 1(b) Pressure sore 1(c) Immobility/stroke II Vascular dementia, Chronic Obstructive Pulmonary Disease, Hypertension, Stroke At the conclusion of the Inquest you set out a number of concerns. These concerns were reported to the Trust and we are now in a position to advise you of what action has been taken to address the issues identified. 1. There has been a complete breakdown in effective communication between the hospital and the family of the deceased. To improve effective communication between the Integrated Transfer Team and the patients and their immediate carers/family regarding the discharge plan, the following actions are being taken. Develop a checklist to ensure all members of the Multidisciplinary Team (MDT) have engaged with patients and their family prior to discharge. The Team leader to ensure through the computer systems between social services and the Trust (IAS/EIS systems) that there is documented evidence that all Integrated Transfer Team (ITT) cases have been discussed with patients and their designated carers. 2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient. To ensure the patients and families wishes are fully raised and given full consideration in the discharge process the following actions have been undertaken: To ensure all patients and families have every opportunity to discuss plans and have a dedicated name and contact number for the social worker managing their discharge. A Leaflet has been produced and is in publication process for patients and carers about “Leaving our Care”. To ensure all newly appointed staff/agency workers are adequately orientated to the hospital and all procedures and policies are outlined from both Tameside MBC and Tameside Foundation Trust (TFT) to the expected standards of practice. All temporary workers located within the Transfer Team will have an induction process and complete the induction checklist within one week of commencing role. Each temporary worker will receive an induction and adequate support and documented regular supervision. 3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress. All patients returning home with care package will have their equipment needs assessed and documented in hospital. Social workers to communicate effectively with the Nurse Coordinators , SO that timely referrals for assessment of equipment needs can be made. The daily length of stay meetings will ensure that the checklist process for discharge is followed. A complex care plan has been formulated for all parties to agree the patient is supported and fully ready for home. 4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge. All plans of care for patients must be shared with the patient and, with patient's consent, their next of kin and agreed before discharge. Each member of the ITT should ensure all care plans are prepared accurately and presented before being discussed and shared. This will be monitored through regular supervision of Tameside MBC staff and through daily length of stay. The ITT supervisors will monitor documentation via Social worker IAS system. The Head of Patient Flow and Team Leader for ITT now have transparency and ability to view and monitor all social worker involvement with cases through Tameside MBC IAS system. This is monitored daily for all cases known to the ITT. 5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place. To improve communication from the ward staff to the ITT through the induction of robust daily SHOP board round. A Pilot of “Sick Patients Home Other Plan” (SHOP) is in progress on two medical wards. This is to be escalated across the trust over the next 3 months and become embedded Practice. This will improve ward based communication to the discharge team and is documented. The SHOP process is a full MDT process daily where all patients are discussed and discharge plans agreed daily. This is documented and evidenced by the ITT team. In addition, the profile of the ITT team is being raised through public awareness and increased visibility and open access e Creating information boards and posters to display across the wards and departments to raise awareness of the team to allow patients, families and carers to have easy access to the team for support and guidance in the discharge process. The team has a social worker available 6 days a week to patients and relatives and a Clinical Discharge Facilitator (CDF) available seven days a week, from 0800-2000hrs to speak with patients, staff and relatives for advice. CDF team are providing training to new staff on their Corporate Induction about planning discharges. ITT team are training all staff on the Nursing documentation relating to discharge and compiling a data base of all staff trained. 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