Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0360, written 5 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Aug 2014 |
|---|---|
| Reference | 2014-0360 |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Interim Chief Executive
Norfolk Community Health & Care NHS Trust
Elliott House
130 Ber Street
Norwich NR13FR
2.
Director of Community Services — Adult Social Care
Norfolk County Council .
County Hall
Martineau Lane
Norwich NR12DH
3. Ms Anna Dugdale
Chief Executive
Norfolk & Norwich University Hospital NHS Foundation Trust
Colney Lane
Norwich .NR4 7UH
CORONER
| am Jacqueline Lake, senior coroner, for the coroner area of Norfolk
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 30 December 2013 | commenced an investigation into the death of JOHN HENRY
WILSHER, aged 96 years. The investigation concluded at the end of the inquest on 1
August 2014. The conclusion of the inquest was medical cause of death 1a) Subdural
Haematoma; 1b) Frailty (Recurrent Falls); c}) Old Age and short-form conclusion
“Accidental Death”.
4 | CIRCUMSTANCES OF THE DEATH
Mr Wilsher was resident in Springdale Care Home (“the Care Home”). His condition
deteriorated in November 2013 and.he had falls on 18 and 25 November 2013. Mr
Wilsher was seen by his GP who referred him to Community Services, Norfolk County
Council ("NCC") for assessment, being of the view that Mr Wilsher was not safe at the
Care Home due to the falls. The Care Home was not made aware of the referral. Mr
Wilsher deteriorated and was seen again by the GP on 27 November 2013 when he was
teferred to the Norfolk & Norwich University Hospital (‘NNUH”) for assessment. A CT
scan was commissioned which showed right extradural haemorrhage and bilateral
subdural haemorrhage.which were considered to be several weeks or even months old.
it was agreed there was to be no intervention and Mr Wilsher was to be kept
comfortable. Mr Wilsher was found to be stable and plans were made for discharge.
NNUH contacted the Care Home to see whether they felt able to care for him due to his
frailty. The Care Home required him to be able to transfer with the aid of one person.
He was assessed by NNUH Physiotherapist on three occasions and stated to be able to
be so transferred, although it was accepted that his mobility was variable. He was
accepted back at the Care Home on this basis. He returned to the Care Home on 7
December 2013. The Discharge Letter gave the Primary Diagnosis as “Right frontal
extradural haemorrhage + bilateral subdural haemorrhage” and Secondary Diagnoses
and Complications as “Urosepsis”. In evidence, the Secondary Diagnoses was
inaccurate. The Care Home quickly became aware they could not cope with his mobility
and Mr Wilsher’s family made arrangements for him to be transferred to a nursing home
on 19 December 2013. In the meantime, on 13 December 2013, Mr Wilsher was
assessed by NCC Community Services Adult Care, when no further action was taken in
view of Mr Wilsher’s impending transfer to a nursing home. The result of the Nursing
Needs Assessment, carried out on 10 December 2013, was not available as at 13
December 2013. Mr Wilsher died on 21 December 2013.
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 itis my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:-
(1) The information contained in the NNUH Discharge Letter is inaccurate;
(2) Concerns were raised by the GP and a referral made to NCC Community Services
on 25 November 2013 as to the suitability of the Care Home in providing care to Mr
Wilsher due to his deteriorating condition. He was admitted to NNUH on 27 November
2013 for assessment and plans were made for discharge to the Care Home. Neither
NNUH nor the Care Home were aware concerns had already been raised (prior to a
further deterioration in his condition) as to the adequacy of the Care Home to cope with
his needs. On Mr Wilsher’s discharge to the Care Home it quickly became apparent they
could not cope with his needs.
(3) An assessment was carried out by NCC Community Services on 13 December 2013
by which time Mr Wilsher had been admitted to NNUH and discharged and plans were
already in place for his transfer to a nursing home.
(4) The outcome of the Nursing Assessment carried out on 10 December 2013 was not
available at the time of the Community Services Assessment.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisations 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 3 October 2014. I, 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:
EE °°)
1am 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 retease or the publication of your response by the Chief Coroner.
Date: 5 August 2014 J lobe.
Jacqueline Lake, Senior Coroner for Norfolk
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.
Rs Norfolk County Council _ Community Services
County Hall
” at your service Martineau Lane
; a NORWICH
Hdip yy oo abl NR12SQ
- Ms Jacqueline Lake 5
HM Coroner 4h tis “4 Tel: 0344 800 8020
69-75 Thorpe Road yt) Fax: 01603 222301
* Norwich _ rey Vi Minicom: 01603 223242
theses
Norfolk NR1 1UA
Please ask for! . Our Ref [ay
Contact Number: iy . Date: 20 October 2014
Dear Madam
Re: John Henry Wilsher deceased
| refer to your report dated 5 August 2014 and should be grateful if you would accept
this letter as the response on behalf of Norfolk County Council Community Services.
| confirm that the importance of giving appropriate feedback to the person who raiséd-
the safeguarding concern ("the referrer’) has been acknowledged and it is agreed
that this should be an integral part of the safeguarding process. The Multi-Agency
Safeguarding Hub (“MASH”) and the safeguarding manager within Norfolk Council
_ have been working with colleagues to ensure this action is embedded in the :
safeguarding process. This will ensure a more outcome focussed safeguarding
process. This will also enable the referrer to be clear when the council has assessed
an issue not to fall within the safeguarding arena. —
In practice this will mean that if similar situation were to arise in the future the
feedback given to the referrer will enable the referrer to raise their concerns directly
with the residential home.
Norfolk County Council Community Services continues to work closely with the
Norfolk & Norwich Community Hospital to ensure safe discharges are made. There
are social care practitioners linked to those Wards which care for older people who, if
requested, are available to support any health staff who are directly in contact with
residential home managers and staff.
‘www.norfolk.gov.uk
a) C)
204 4 INVESTOR SN PEOPLE
| trust this deals with your concerns but if there is anything else | can assist with then
please do not hesitate to contact me.
Yours faithfully
FS
Director of Community Services
www.norfolk.gov.uk
2)
ie ‘ ty.
2074 Fao
oO Our Vision Norfolk and Vane’ University Hospitals AYk3 with the care we went . for those we love the most ANN} NHS Foundation Trust Norfolk & Norwich University Hospitals wet pi W\\ Trust Management ue if NHS Foundation Trust Ms Jacqueline Lake HM Coroner Pat ro Colney Lane 69-75 Thorpe Road Ov ee” Norwich NR4 7UY Norwich : wee" NR1 1UA , a 29 September 2014 Dear Ms Lake | write further to the report dated 5 August 2014 that you issued following your inquest into the death of Mr John Wilsher in December 2013. We have reviewed your report carefully and can respond particularly to your concern number 1 ie that the discharge letter from this hospital contained inaccurate information. A review of incidents relating to discharge from hospital trusts was published by NHS England in August 2014. In fact, a stream of work concerning this was already underway within the Trust, led by one of our Associate Medical Directors a and involving a number of stakeholder parties, including GPs, consultants, junior doctors ete. The outcome of that work was presented to our Executive Board at the beginning of September and a series of steps are being put in place to improve the accuracy of discharge information provided to GPs and community services. The aim of these changes is to ensure speedier completion of electronic discharge letters, a more ‘rounded’ picture of the patient and improved continuity of care. The steps being taken may be summarised as follows: * Revision of the template discharge letter, to make this easier to complete and give prominence to the most important information; * Creation of an additional bespoke template letter for patients of our Older People’s Medicine Department (such as Mr Wilsher), with fields specific to the issues affecting this group of patients; ¢ Revision of the prompts guiding clinicians when completing these letters, to ensure all relevant information is included; e Changes to the training programme associated with use of the templates. We will continue to monitor the effect of the changes outlined above and whether any further steps are necessary to promote the safe transfer of care between hospital and community. The Trust sees up to a million patients a year and we recognise the importance of good communication between healthcare providers. Your concerns have been raised with the junior doctor who wrote the discharge letter, to ensure that he is fully aware of the implications of inaccurate information being provided. | hope that this information provides you with the assurance you need but if it would be helpful to discuss please let us know. Yours sincerely Anina Dugdafe Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.