Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0504, written 17 Nov 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 Nov 2014 |
|---|---|
| Reference | 2014-0504 |
| Deceased | Peter Dorney |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| 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 (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. Chief Executive Southmead Hospital CORONER lam Maria Voisin, Senior Coroner, for the Area of Avon 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 15th April 2014 | commenced an investigation into the death of Peter DORNEY , Aged 64. The investigation concluded at the end of the inquest on 14th November 2014, The conclusion of the inquest was a narrative which read as follows Peter Dorney had a complex medical history. He was in hospital and unwell. Overnight on the 3/4" April 2014 he deteriorated; increased observations were not carried out and a senior member of staff was not notified as they should have been; this resulted in the lost opportunity to render medical care and treatment. He died on 4" April due to bronchopneumonia The medical cause of death was recorded as: la Bronchopneumonia \| Alcoholic liver disease CIRCUMSTANCES OF THE DEATH Peter Dorney was admitted into Frenchay Hospital on 29" March, during his admission it was clear that he was not a well man. During the ward round on 3” April there was no evidence at that time of a chest infection. Overnight on 3/4" April the nurse caring for Peter Dorney said that at 22:00 hours his EWS score was 2 due to his low oxygen saturations. This score of 2 should have resulted in her informing the nurse in charge and increasing his observations to hourly. In evidence she said that it was her intention to do both of these things and that she should have but she didn’t. When Peter Dorney’s observations were carried out at 07:40 hours on 4" April he was now very unwell and his EWS was 5. Appropriate action was then taken however later that day he suffered a cardiac arrest and died. 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. — During the evidence the ward sister gave evidence and she was of the opinion that there should be mandatory training on EWS for nurses. It was clear in the evidence that the protocol in relation to the EWS score was not followed and | was told that the EWS training was not mandatory currently. This case highlights why EWS scores are so important to the well-being of patients 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 44" January 2015. 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 — the family of Mr. Dorney. lam 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. 417" November 2014 M.E. es
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.
North Bristol [i NHS Trust Trust Headquarters Southmead Hospital Southmead Road Westbury-on-Trym Bristol BS10 5NB Tel: Website: htto://www.nbinhs.uk Ms Maria Voisin HM Senior Coroner The Coroners Court Old Weston Road Flax Bourton BS48 1UL ae 14 January 2015 Dear Ms Voisin, Re: Peter Dorney Inquest 14 November 2014, Regulation 28 Report Further to your narrative conclusion and concerns raised to North Bristol NHS Trust in the form of a Regulation 28 Report, | am responding to confirm the Trust's actions. At the inquest, | understand the Ward Sister gave evidence that Early Warning Score (EWS) training is not mandatory at the Trust for nurses and she was of the opinion that it should be. This is not completely accurate. All new nurses (both NBT Extra and NBT) receive mandatory EWS training on induction at the Trust. The clinical induction programme takes place over 3 days and includes a 30 minute training session on EWS/SBAR (Situation, Background, Assessment and Recommendation). This induction programme has been in place since 2011. For those nurses who have been at the Trust prior to when this induction programme commenced, EWS training is not mandatory, but is carried out as appropriate. This training is included in a nurse’s Blue Passport (a training record used by every nurse) and carried out as appropriate i.e. when a member of staff is deemed to require it. Training requirements are discussed at an individual's annual appraisal and during the course of the year, if necessary. | have set out below the system at the Trust in relation to EWS training. North Bristol Trust implemented the Bristol Observation Chart in 2007 as part of joint safety collaborative work with University Hospitals Bristol. The Bristol chart makes it very clear when a patient triggers an EWS, and our policy covers the process of escalation to medical staff that must be responded to within a timed period depending on the severity of the score. As mentioned above, all new nurses are trained on induction in the EWS score, and the vast majority of nurses have had this training. Since receiving the Regulation 28 Report, each directorate has reviewed which individuals have not received the training and measures are being put in place for those individuals to receive this. This has been limited to a few staff that have been employed at North Bristol NHS Trust for more than a few years. As of 13 January 2015, our records show that 93% of all nurses (both NBT extra and NBT) have received EWS training. This is well above our target range for compliancy within any given subject, which is assessed at 85%. | am confident that we have the right EWS training in place for all nurses, and that those few individual nurses (7% as of 13 January 2015) that have been identified as not receiving the training following a review by each directorate, will have received the training within the next 3 months. Yours sincerely Andrea You Chief Executive
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