Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0271, written 17 Jun 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 Jun 2014 |
|---|---|
| Reference | 2014-0271 |
| Deceased | Audrey Garland |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| 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 Officer , Blackpool Teaching Hospitals NHS Foundation Trust and to The North Shore Surgery, Blackpool. CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester 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 2™ December 2013 | commenced an investigation into the death of AUDREY VERA GARLAND dob 31° December 1935. The investigation concluded on the 25" April 2014 and the conclusion was one of a narrative verdict. The medical cause of death was 1a Bronchopneumonia 1b Ischaemic gangrenous ulceration of the legs and feet 1c Peripheral vascular atherosclerosis 11 Coronary artery atheroma, Hypertension. 4 CIRCUMSTANCES OF THE DEATH In April 2013 Mrs Garland developed a small spot on her leg. She telephoned her doctor and was apparently prescribed antibiotics. In June 2013 she was visited at home by two doctors from the GP Practice and it was noticed that she had necrotic wounds to her right foot. She thereafter had treatment by the District Nurses. By the beginning of September her wounds were worsening and she was seen again by the GP. Two attempts were made to get her to an outpatient appointment at the hospital. Because of transport difficulties she was unable to attend either of these appointments. On the 12™ September 2013 she was seen at home by her GP who did not examine her legs as there was no nurse to re-dress them. The GP now accepts that it would have been preferable for a District Nurse to have accompanied him on the appointment. The GP also conceded that it would have been better had a doctor visited Mrs Garland on the 21* August 2013. It has also been conceded by the Head of Service that the District Nurses did not carry out their duties correctly. By the time Mrs Garland was moved to the Stockport area she was extremely thin with extensive gangrenous necrotic ulceration and was in a “terrible state”. Thereafter despite the attentive care of the medical and nursing authorities and the care and attention of her family, Mrs Garland’s condition continued to worsen until her death. During the course of her treatment whilst she was living in the Blackpool area, opportunities were missed to provide her with the optimal level of medical and nursing care. 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 was a failure by the GP practice to recognise or fully appreciate the severity of the ulceration to her legs. 2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering. 3. Despite the fact that she was considered to be in need of an outpatient appointment at Blackpool Hospital on two separate occasions, this did not take place because no-one organised transport for her to get to and from the hospital. 4. A home visit from the GP took place on the 12" September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs. 5. The District Nurses did not perform their duties correctly in a number of ways as conceded at the inquest by their Head of Service. 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 13" August 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to qo ee Persons a (daughter of the deceased), (Care Manager) (Clinical Nurse Manager). | have also sent it to CQC 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. Date John Pollard, HM Senior Coroner 17™ June 2014
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.
(1a BS/lolp = reg 18/6 ry. Blackpool Teaching Hospitals INHS NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR Telephone: 01253 303470 07 August 2014 Mr John S Pollard Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG RECEIVED 1§ AUG aniq Dear Mr Pollard Re:_Audrey Garland (Deceased) Ref: JSP/KA/02556-2013 Thank you for your letter dated 17" June 2014. Please find our response below. Matters of Concern 2. There was a failure by District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering. 5, The District Nurses did not perform their duties correctly in a number of ways as conceded at the inquest by their Head of Service. Introduction As a result of an internal investigation into the care Mrs Garland received some areas of concern had been identified. Two focus group meetings took place with the team on 11" March 2014 and 17" April 2014 to discuss these areas of concern. Following the inquest on 25" April 2014, the details of the findings and concerns raised by the Coroner were discussed with the District Nursing Team on the 30" April 2014. This meeting was attended by all of the team members who were involved in Mrs Garland’s care. The outcome of the meetings and actions are detailed in an action plan monitored by the Head of Service. The action plan covers a number of specific themes: e Leadership e Record Keeping e Communication with the GP practice e Mental Capacity Act and Deprivation of Liberties Documentation specifically in relation to a record of risk assessments — MUST, Waterlow, Skin Integrity and Pain 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 Information Standard Certified member Chairman: Mr lan Inhnsnan kA A 1d RA Patient Safety INVESTORS | ar IN PEOPLE , GO!4 Blackpool Teaching Hospitals NHS) NHS Foundation Trust e Communication with patient and carers. e Non-compliance policy and escalation. Taking action to address these themes will improve patient care, reduce harm and prevent future deaths. Matters of concern a There was a failure by District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering. Clinical supervision has been strengthened, specifically in relation to the management of leg ulcers. Supervision — in the form of joint visits with a senior nurse is happening daily on a rotational basis with individual members of the team. This is to support the changes in practice required and to ensure good practice is embedded. Individual nurses are also having more focused support by a senior nurse in the management of wound care and how to manage wound infection. Any ulcer that fails to improve or deteriorates and there is an issue of noncompliance is highlighted using the organisation’s untoward incident system. Joint visits with other health care professionals such as the Specialist Tissue Viability Advisor and General Practitioners to review patients with deteriorating wounds are now embedded into practice within the team. A training needs analysis for the team has taken place and clear individual plans to meet their learning needs are under development in line with the organisation's appraisal system. All members of the team will have a personal development plan to support their learning and development by the end of August 2014. A separate training needs analysis with a focus on diabetes care is currently underway as part of the development of diabetes skills across the whole of the community nursing workforce. Training will then be developed and plans put in place for the team to attend. The team has an improved understanding of the referral processes to secure Tissue Viability Advisor support in relation to complex wound management. In line with best practice standards, the measurement of wounds and documenting progress or deterioration are now being monitored robustly by the team. 5) The District Nurses did not perform their duties correctly in a number of ways as conceded at the inquest by their Head of Service. The following themes were identified as areas that needed addressing within the team to improve performance in the delivery of safe care for patients. Improvements in leadership capabilities within team specifically with regard to problem solving A new Clinical lead was appointed to the team in June 2014. This role will focus on improvements in clinical standards and compliance with clinical supervision. The clinical lead has a clear action plan with priorities for delivery. The action plan was developed in early June in conjunction with the Clinical Improvement Team within the Division. A daily face to face clinical handover of care is in place with high risk complex patients being identified and clinical discussions held in order that all members of the team are aware of the risks and the actions required to support good clinical care and improvement. Record keeping — Documentation, and Risk Assessment Record keeping audits are now undertaken quarterly within the team as part of a wider organisational requirement. There is an agreed single set of new clinical records which will be introduced into community settings in August 2014. Performance management systems are now in place with individuals being called to account when their clinical practice fails to meet the required standard. This includes joint visits, reflective practice Blackpool Teaching Hospitals [779 NHS Foundation Trust and development plans. If performance does not improve there is an option to manage individuals under the management of performance policy within the organisation. Improvements needed with regard to communication with the General Practitioner A series of meetings are being held with the GP practice to improve communication. A meeting was held with Mrs Garland’s GP on 8" May 2014, followed by regular review meetings with other key professionals within the practice during June and July to further develop relationships with the practice based team. A review meeting has been agreed with Mrs Garland’s GP for 1° August 2014. Implementation of the EMIS web electronic record system later in 2014 will further enhance effective communication as joint records will then be available to all staff working in primary and community care settings. Team trained in Mental Capacity Act and Deprivation of Liberty A training event was held on 18'" June 2014 which focused on Mental Capacity Assessment and Deprivation of Liberty standards. All of the team attended to ensure they understand how to assess mental capacity in patients. The team has also been trained during clinical supervision in the use of the Trust non-compliance and escalation policy in order that every effort is made to ensure patients understand the choices available to them and the implications of non-compliance. Improvements needed with regard to communication with families and carers The team are aware following the series of reflective meetings of the need for effective communication with families and carers to ensure they are made aware of any risks associated with patient care and any actions being planned to support the patient. The team recognise following the lessons learnt as part of Mrs Garland’s care that all communications with families and carers should be clearly documented in the nursing record. Yours sincerely DIRECTOR OF NURSING AND QUALITY
See every Prevention of Future Deaths report matching Blackpool Teaching Hospitals 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.