Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0387, written 29 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 | 29 Aug 2014 |
|---|---|
| Reference | 2014-0387 |
| Deceased | Irshad Ali |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Irshad ALI (died 07.05.14)
THIS REPORT IS BEING SENT TO:
1.
Medical Director
Barts Health
Royal London Hospital
Whitechapel Road
London E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 8 May 2014, I commenced an investigation into the death of Irshad
Ali, aged 79 years. The investigation concluded at the end of the inquest
on 27 August 2014.
I made a determination at inquest that death was caused by an accident,
when Mr Ali fell in the Royal London Hospital in the early hours of 25
March 2014 and hit his head, at the time suffering severe liver cirrhosis.
His medical cause of death was:
1a bronchopneumonia
1b traumatic intracranial haemorrhage
2 end stage non alcoholic steatohepatitis cirrhosis
1
4
CIRCUMSTANCES OF THE DEATH
Mr Ali was admitted to hospital on for drainage of ascites. He was found
on the floor of the ward at 4am on the morning of 25 March, having
apparently sustained an unwitnessed fall. He left the hospital at lunch
time, under the impression that he had been discharged. He later re-
presented to the emergency unit, and was diagnosed with a massive
head injury. In view of his end stage liver disease, surgery was not
advised. He died six weeks later of a consequent chest infection.
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. The nursing staff should have checked on Mr Ali every two hours
through the night, but there was no record of intentional rounding
on 24/25 March. There was a record of the night before and a
record of the night after, but not the night that Mr Ali fell. The chart
appears to have gone missing.
2. Though the senior sister looking after Mr Ali on the morning of 25
March assured me that neurological observations were carried out
hourly after his fall, there was no record of this. Again, the chart
appears to have gone missing.
3. The consultant in charge of Mr Ali’s care stipulated that his junior
medical colleagues should perform neurological observations
before Mr Ali could be discharged, yet this did not take place.
The sister in charge told me that she asked the registrar if Mr Ali
was neurologically stable enough to be discharged, and she said
yes.
4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali
should undergo physiotherapy assessment before he could be
discharged, yet this did not take place.
The sister in charge told me that she knew about this and she
knew that a physiotherapist was going to review Mr Ali that
afternoon. However, she did not pass this information on to the
nurse who looked after Mr Ali during the sister’s lunch break, nor to
Mr Ali’s family.
2
The nurse said that she did tell Mr Ali’s family he was not ready for
discharge, but she gave them the discharge paperwork before she
went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that
they now think that discharge packs should not be given out until
the patient’s discharge is complete.
5. Both the doctor and the nurse thought that it would be helpful to
have a nurse accompany the doctors on their ward rounds.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 27 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
children of Irshad Ali
Royal London Hospital
Royal London Hospital
I 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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
3
9
DATE SIGNED BY SENIOR CORONER
29.08.14
4
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.
Barts Health INHS| NHS Trust Coroner ME Hassell Senior Coroner Trust Headquarters Inner North London Executive Offices St Pancras Coroner’s Court Ground Floor Camley Street Pathology and Pharmacy Building London The Royal London Hospital N1C 4PP 80 Newark Street London E1 2ES 17 October 2014 By special delivery Dear Coroner Hassell Inquest Touching the Death of Irshad Ali | write in response to your Regulation 28: Report to Prevent Future Deaths, dated 29 August 2014. The investigation into your concerns regarding the lack of documentation recording intentional rounding on the night of 24/25 March 2014, the missing chart recording neurological observations carried out after his fall, the lack of documentation of the neurological examination carried out by the consultant's junior colleagues, the lack of a physiotherapy assessment prior to discharge, that this was not communicated by the nurse-in-charge to her colleague and to the family, the provision of the discharge pack to the family when he was not yet ready to be discharged, and the evidence that a nurse accompanying the doctors on their ward rounds would be helpful, has now been concluded. | am satisfied that this investigation has been sufficiently robust, in that we have scrutinised all relevant records and interviewed staff to inform our investigation. | write to apprise you of the conclusions of the investigation. During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did také place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes. The missing neurological observation chart has been located and it confirms that appropriate neurological observations were carried out after Mr Ali’s fall. This chart had been inadvertently misfiled. Senior medical staff have confirmed that the induction for new medical trainees now includes a section on documentation and management of falls, emaphasising the requirement to document actions in the medical records. To ensure that all future referrals (including physiotherapy referrals) made for patients are signed and dated in the medical notes when actioned, staff have been reminded of the importance of thorough clinical handover. This will be further highlighted during a twice daily staff safety briefing, and followed up by spot checks of patient notes to check that verbal referrals are being documented as actioned. Barts Health INHS| NHS Trust To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations, is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations. It is Trust policy that the copy of the patients’ discharge letter should be given once all facets of the discharge process are complete. Nurses have been reminded of the policy and the requirement to update the patient information sheet with the information that the discharge summary should be given to the patient alongside their discharge medications. To facilitate this, the Trust continues to cultivate a continued effective relationship with the Trust discharge lounge. Ward 14F currently has five specialties, all of which carry our doctors ward rounds. To enable a nursing presence on each of the ward rounds, the senior sister will be given a copy of the consultants’ rota and proposed time of ward rounds, and agreement has been reached that the doctors will not leave the ward until they have verbally communicated the proposed plan of care for their patients to the Nurse in charge of the ward, or responsible for that group of patients. This will be reviewed daily with the feedback provided by the consultants, with a weekly combined nursing and medical review. We have taken this as an opportunity to review our processes to enhance future care. The outcome of the investigation will be shared with all Trust medical and nursing staff, to ensure that staff involved implement the above changes and audit the adequacy and effectiveness of the changes. Thank you for bringing your concerns to my attention. | trust that you are assured | have taken them seriously and investigated them appropriately. Yours faithfully Medical Director Barts Health NHS Trust
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