Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0382, written 22 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 | 22 Aug 2014 |
|---|---|
| Reference | 2014-0382 |
| Deceased | Martin Hill |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| 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.
THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LAW)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A 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. Matthew Kershaw Chief Executive, Brighton & Sussex University Hospitals, Royal Sussex County Hospital, Eastern Road, Brighton. Nurse / Matron in Charge of Level 9A Nurse in Charge of ail Nursing at the Hospital Chief Pharmacist with regard to the MAR (Medical Administration Records) Charts Dr. in charge of A&E ee. Consultant General Surgeon RSCH PaRen 1 CORONER lam Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 2 CORONER'S LEGAL POWERS t 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 8" April 2014, | commenced an investigation into the death of MARTIN ARNOLD HILL. The investigation concluded at the end of the inquest on 8" August 2014 .The conclusion of the Inquest was — A Narrative Conclusion 4 CIRCUMSTANCES OF THE DEATH Please see Record of Inquest. 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 CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPLFRCA GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 The MATTERS OF CONCERN are as follows. — (1) Although this man arrived in A & E on the 28" March 2014 at approximately 12:30, having been suffering confusion, abdominal pain and vomiting for some three days with raised white cell count and markedly raised C-Reactive Protein. He was not commenced on antibiotics until over 48 hours later at 14:00 hours on the 30" March, 2014. At Inquest | was told that he should have been commenced on Pragmatic antibiotics shortly after his arrival and assessment by a Doctor in A & E. At 20:00 hours on the 28° March 2014 after he had been admitted to The Royal Sussex County Hospital, Brighton his NEWS rose from 1 to 6. NEWS’ own Guidance and the Hospital’s Protocol require that Mr. HILL should have been referred to the Critical Care Outreach Team. He was not. His NEWS rose to 6 again on the 30” March 2014 at 00:20 hours, However, he was not referred then either. He was not referred to Critical Care Outreach until his NEWS rose to 10 at 07:00 hours on the 30” March 2014. 8 (3 a Whilst it is noted that Mr. HILL was admitted at funchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28" March at 22:15 hours and another 2mg of Diazepam at 09:00 on the 30" March. Also on the 30” March PABRINEX was considered and he was written up for this, although this was not given. On the 30” March at 09:50 hours he was given 5mi of METHADONE and later at 13:00 on the 30" March he was given another 5mi of Methadone. (NB: His daily Methadone prescription was 50ml) S When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28" March 2014 but this information was not apparently noted by the Doctors who were stil! talking about constipation over the next 24 - 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking. (5 There are serious omissions on the Medical Administration Record. | was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend. Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND your organisation have the power to take such action. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LAW)HONS 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report (22/8/2014), namely by 17th October 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 1. _Family members of the late Mr. Martin Arnold Hilt:- .. Sister .. Daughter | .. Daughter .. Brother | have also sent it to:- (1) Secretary of State for Health, Department of Health. (2) Sir David Nicholson/Simon Stevens ~ Chief Executive NHS England. (3) National Patient Safety Agency. ' (4) Care Quality Commission (5) ~ Medico Legal Services Manager Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE. 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: 22" August, 2014 SIGNED BY: . le HOME Senior Coroner Brighton and Hove
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.
The Shrewsbury and Telford Hospital INHS
NHS Trust
17 OCT 2016
Mr JP Ellery, Senior Coroner for Shropshire Princess Royal Hospital
Telford and Wrekin Area Apley Castle
H M Coroner's Service Telford
Third Floor Shropshire TF1 6TF
Guildhall Te:
Fox:
Frankwell Quay
Shrewsbury SY3 8HQ
Your ref: |
-Date:-10-October-2014——--—-
Dear Mr Ellery,
Regulation 28 following an Inquest into the death of Martin Rowland Hill
Thank you for your letter of 6 August, 2014, setting out the matters of concern found following the
death of Mr Hill. As you are aware, when a "serious incident" has occurred within the Trust, the
Trust undertakes an investigation into the incident. One of the categories for a serious incident is if
it caused or contributed to an unexpected or avoidable death. From the Post Mortem report and
subsequent addendum letter, we were led to believe that the care provided at the hospital had been
appropriate and therefore no serious incident investigation took place. Following evidence during
the Inquest , we have now begun a high-risk review into Mr Hill's death. Our investigation is ongoing
at this time.
in addition to the investigation currently being carried out, we have also reviewed the areas in which
you have raised concern within your letter and | will address each of these in turn.
Concerns over the review and actioning of x-ray reports within the Accident & Emergency
Department
There is a currently a piece of work ongoing within the Trust to improve electronic reporting
systems. The Trust is looking towards utilising a system called "Order Comms" for radiology. This
system will allow referrals for radiographic examinations to be sent electronically to the Radiology
department. This electronic request will, if accepted, automatically populate the RIS (Radiology
Information System). This reduces the turnaround time for requests received. It also provides an
audit trail for when a request was sent to the department. The second haif of this system covers
reports sent out. With the new system, the Accident & Emergency department will be able to
monitor if a report has been read and then actioned. There will bea requirement for all referrers to
click a button to say that the report has been read and actioned. Ifa department is not undertaking
this action, we will be able to flag this up as a clinical governance issue.
Trust web site: www.sath.nhs.uk 1
Given that this system will not be in place imminently, we have also reviewed the processes within
the Accident & Emergency department and a more robust process of checking x-ray results and
actioning abnormal reports has been developed and approved by the department. This system
ensures that the x-ray results are checked regularly within the department and actioned where
necessary. This should prevent recurrence of what happened in Mr Hill's case. | attach a copy of this
process for your assurance. | would like to add that GP practices are able to electronically access the
X-ray reports from the hospital and can access these at any time.
Mr Hill was discharged without any medications
Mr Hill was transferred from the Accident & Emergency department to the Clinical Decisions Unit
("CDU") prior to discharge. He was therefore discharged from the CDU and not the Accident &
Emergency department. There is a process in place on the CDU with regard to patient discharges. If
a patient requires a prescription that is not in stock or is not available, the staff will ensure thata
community prescription (FP10) is given to the patient/carer to take away with them so they can
obtain their medication following discharge. It appears that on this occasion, unfortunately, Mr Hill
was not given his community Prescription to go home with. I can only apologise for this omission
_ _.._._and can assure you that all staff-have-been-reminded-of the importance of ensuring that they follow
the process in place.
In addition, the Pharmacy department have recently updated their Medicine Codes Policy which
includes a clear flowchart on how to deal with patients who are discharged outside of Pharmacy
hours, as was the case in Mr Hill's care. l attach a copy of the process which should be followed by
all clinical areas to ensure that patients will be discharged with either medication or a suitable
prescription for them to obtain medication from a community pharmacist. The Matron responsible
for the CDU has now ensured that the staff on working within the CDU are familiar with this
flowchart and will refer back to the same when arranging for a patient to be discharged.
Concern over GP not receiving the discharge summary
' note that you have asked for some reassurances surrounding the current discharge process. | can
confirm that the current process within the Accident & Emergency department on discharge
summaries is that once the doctor in the department has written the letter to the GP, it is then
transcribed by the coding staff. This is then sent either electronically by email, or if the GP practice is
not on the electronic system, it is posted or faxed. This process is carried out within 48 hours.
The process for discharge summaries with patients from the CDU is slightly different and, at the
present time, the discharge summaries on the CDU for Accident & Emergency department patients
are handwritten. A copy of the summary is handed to the patient and a GP copy is generated. The
GP copy is then either given to the patient to give to the GP or is sent in the post. This process is
Currently under review and it is anticipated that the CDU will soon be utilising the electronic
discharge summary process that the other wards in the hospital use. This will, however, require
training and is therefore not yet in place.
| was pleased to hear that the GPs at the Inquest noted that they usually receive their discharge
summaries which they said were promptly received following discharge of patients from the
hospital.
Trust web site: www.sath.nhs.uk 2
'hope | have been able to offer you assurances that the Trust has taken action to prevent further
recurrences of the problems that were encountered by Mr Hill prior to his death.
Please do contact me if you require any further information.
Yours sincerely,
Peter Herri
Chief Executive
Trust web site: www.sath.nhs.uk 3
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