Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0064, written 17 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Feb 2014 |
|---|---|
| Reference | 2014-0064 |
| Deceased | Laura Hill |
| Coroner | Joanne Kearsley |
| 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, Stepping Hill Hospital 1 | CORONER | am Joanne Kearsley, Area 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 the 9" October 2013 | commenced an investigation into the death of Laura Hill date of birth 13.09.1936. The investigation was concluded at the end of the Inquest on the 5" February 2014. The conclusion of the Inquest was that the deceased had died as a result of 1a) Pneumonia 2) Chronic Obstructive Pulmonary Disease, Ascending Cholangititis, dislocated left hip replacement requiring manipulation, Vascular Dementia, Rheumatoid Arthritis and immunosuppression treatment. | returned a conclusion that she had died as a result of natural causes. 4 | CIRCUMSTANCES OF THE DEATH: On the 28" September 2013 the deceased presented to Stepping Hill Hospital with acute abdominal pain and sepsis due to cholangitis. She had an extensive complex medical history. She was admitted for treatment initially to the Surgical Assessment Unit. She was initially treated with antibiotics and was not considered fit enough to undergo MRCP procedure. On the 1°‘ October the deceased was transferred to ward B6. At 03.50am on the 2™ October the deceased was seen to fall from her bed, as a result she sustained a fracture to her left hip. This required manipulation and needed several attempts before this was successful. The deceased continued to deteriorate and died on the 8" October 2013. The death was initially reported to the Coroner’s Office with a cause of death offered as 1a) Pneumonia and 1b) Manipulation under anaesthesia for displacement of left total hip replacement. At the inquest | heard evidence that the pneumonia was on balance due to her admitting condition and a number of co-morbidities. However | also heard evidence that on her admission to hospital no Falls Risk Assessment was carried out, that she was transferred between wards at 01.30am and that on arrival on Ward B6 where she had her fall there was again no Falls Risk Assessment carried out. It was noted that the deceased would in all likelihood have been assessed as requiring cot sides (albeit that does not prevent someone falling) and identified as at high risk of falls. 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. Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs Hill was in hospital for this to be carried out. There was no assessment on her admission to Ward C3 nor when she was transferred to Ward B6. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14” 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 cay i son of the deceased, and to the Coroners’ Society Website. | 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. 17™ January 2014 Joanne Kearsley, HM Area 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.
/yQ O8fhonp 97-44 Stockport NHS Foundation Trust Our ref. AB/RF/CM/PR-letter to HM Coroner-l=L-Hill Oak House Your ref. JK//KA/02190-2013 Stepping Hill Hospital Poplar Grove H. M. Coroner Stockport Coroner’s Court SIZE Mount Tabor Telephone: 0161 483 1010 Mottram Street Fax: Stockport SK1 3PA 31% March 2014 Dear Ms Kearsley Re: Laura HILL 13.09.1936 (Deceased) Thank you for your letter of 17" February 2014, concerning the inquest of the above named. As always, I am grateful to you for highlighting your concerns on the Regulation 28 ‘Report to prevent future deaths’ and for providing me with an opportunity to respond. Ms Hill was admitted to Ward C3 on 28th September 2013 and on admission a falls risk assessment was completed. Ms Hill was identified to be at risk of falls and as a result of that assessment bed rails were recommended. The nurse who carried out the falls risk assessment has stated that, prior to attaching the falls risk wrist-band and completing the care plan, she went to find bed rails for the patient but could not find any immediately; she then became very busy and unfortunately forgot to go back to attach the falls risk wrist-band, fit bed rails and complete the care plan. On 1* October 2013, shortly after 01:00 hours, Ms Hill was transferred to Ward B6; however the falls risk assessment was not updated by the nursing staff, as per the trust policy, and on 2™ October 2013 at 03:30 hours Ms Hill had an unwitnessed fall. Actions We have instigated an escalation process whereby, if any equipment cannot be located within the mmediate ward environment, staff must contact the senior nurses on ‘professional cover’ for the Business 3roups by bleep in the first instance to assist in locating the equipment. Should the bleep-holder be unable 0 resolve the problem, this is to be escalated to the hospital site manager who will either locate the 2quipment or assist in the re-assessment of those currently in use across the hospital. This will be nonitored via the Datix incident reporting system to ascertain the need for further equipment to be vurchased. is a result of our investigations, in the case of the falls risk assessment undertaken on ward C3, the nurse ailed to follow Trust Policy in applying the falls risk wrist-band and in completing the falls risk care plan; ad she done so this would have alerted other staff to the fact that the patient was at a higher risk of falls. he nurse concerned has been formally counselled on her failure to follow Trust Policy. 1 the case of the nurse on ward B6, who failed to update the falls risk assessment on transfer of Ms Hill, 1e investigation found that she had also failed to follow Trust policy and she too has been formally dunselled regarding this. iis case has been presented by the managers of both wards involved to a wider audience of ward anagers at a Surgical Sisters’ meeting on 17 March 2014, so that they may disseminate the lessons arned to their respective teams. our Health. Our Priority. I hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hégitate to contact me if you have any further questions regarding this matter. Ann Barne Chief Executive
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