Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0563, written 16 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2014 |
|---|---|
| Reference | 2014-0563 |
| Deceased | John Leyin |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| 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.
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: Basildon Hospital 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 2 CORONER’S LEGAL POWERS I 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 3 June 2013 I commenced an investigation into the death of John Charles Leyin. The investigation concluded at the end of the inquest on 2 December 2014. The conclusion of the inquest was that Mr Leyin died as a result of a recognised complication of a necessary medical procedure. The cause of death was 1a) Iatrogenic lung injury 1b) nasogastric tube insertion 1c) intracerebral haemorrhage 4 CIRCUMSTANCES OF THE DEATH Mr Leyin was admitted to Basildon Hospital on 10 April 2013 suffering from a stroke. He failed to recover and there were serious difficulties with feeding arrangements. A PEG could not be inserted successfully and a nasogastric tube was in error placed into Mr Leyin’s lung. He continued to deteriorate and died on 1 June 2013. 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) There was a failure on the part of the Hospital to ensure the dissemination of Trust Policy and NPSA Guidance to all staff. (2) There were weaknesses in the training systems in place (3) Checks were not made as to whether or not staff were up to date in their training for carrying out procedures such as the insertion of a nasogastric tube. (4) At any one time there seemed to be a lack of knowledge as to how many trained staff were on duty to carry out such procedures 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your 1 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 10 February 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – I am also under a duty to send the Chief Coroner a copy of your response. and to the Care Quality Commission 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. 9 16 December 2014 Caroline Beasley-Murray 2
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.
Basildon and Thurrock University Hospitals INHS' NHS Foundation Trust Basildon University Hospital Nethermayne Basildon Mrs Caroline Beasley-Murray Essex SS16 5NL Her Majesty's Coroner HM Coroner's Court Tel: 01268 524900 A Block — Ground Floor . Country Hall www. basildonandthurrock.nhs.uk Victoria Road Chelmsford CM1 1QH 9 February 2015 Dear Mrs Beasley-Murray Report to Prevent Future Deaths (Regulation 28) in the case of Mr John Charles Leyin Further to your letter dated 16" December 2014, in which you provided a Report to Prevent Future Deaths, | have reviewed the content and the points that you have raised as matters of concern, in which you consider further action should be taken. Foliowing Mr Leyin’s death in July 2013 an investigation was undertaken to explore the circumstances leading to this event and evidenced specific issues relating to care delivery. An associated action plan was developed to ensure that rapid and robust work was undertaken to ensure that a similar incident did not happen again at the Trust. In addition, work was already underway to change the manner in which Trust policies and procedures were cascaded across the Trust. | understand that Nutritional Nurse Specialist provided evidence of this to the Inquest. Thereby | have outlined the detail of these actions alongside the concerns as you have raised them in the hope that these will reassure you that the Trust has already sought to address these issues. 1. There was a failure on the part of the hospital to ensure the dissemination of Trust Policy and NPSA Guidance to all staff. Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinica! Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non- compliance is addressed quickly and efficiently. 2. There were weaknesses in the training systems in place. The training system was reviewed as a result of this incident and weaknesses noted. The whole system and way the NG competence training was undertaken was strengthened. a. Only Nutrition Nurse Specialists to deliver theory training. b. Only designated NG Assessors are allowed to assess competence. The list of assessors kept by the Nutrition Nurses. c. NG Competence divided into 3 parts 1) theory training 2) Part 1 (allowing nurses to manage patients with nasogastric tube feeding, verify tip position and administer feed and medication) 3) Part 2 (Place NG feeding tube) d. All competency training records, once completed, are sent to the Nutrition Nurses for verification, then training record compliance is sent to Staff Learning and Development to add to their individua! staff record e. Monthly NG competence compliance circulated by Staff Learning and Development to Heads of Nursing and Senior Ward Sisters (and Nutrition Nurses) 3. Checks were not made as to whether staff were up to date in their training for carrying out procedures such as the insertion of a nasogastric tube. It was clear following the incident that additional checks were required to ensure compliance with training. As the manager responsible for the team the onus is on the Senior Ward Sisters to maintain their records locally. However, the monthly competence compliance report is circulated to the Heads of Nursing and Senior Ward Sisters as a fall back mechanism and enables them to keep track of their staff records as well. Paper copies of the nurses’ Competency Framework are kept in staff records. on the ward. 4. At any one time there seemed to be a lack of knowledge as to how many trained staff were on duty to carry out such procedures. | hope | have responded fully this specific point through the answers provided to questions 2 and 3. | hope that this has provided you with sufficient assurance that we have undertaken a series of actions to mitigate any risk of a similar incident happening again. Further assurance can be provided through training records that are held locally at the Trust. Yours sincerely
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