Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0015, written 20 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jan 2015 |
|---|---|
| Reference | 2015-0015 |
| Deceased | Awa Jeng |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Peter Morris, Chief Executive, Barts Health, Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB 1 | CORONER | am Nadia Persaud, senior coroner for the coroner area of Eastern District of Greater London 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. http://www. legislation.gov.uk/uksi/2013/1629/part/7/ 3 | INVESTIGATION and INQUEST On the 30" December 2013, | commenced an investigation into the death of Mrs Awa Jeng. The investigation concluded at the end of the inquest on 12” January 2015. The conclusion of the inquest was a narrative conclusion: Mrs Jeng was admitted to Newham General Hospital on the 18” December 2013 following a fall at home. She underwent a left hip hemiarthroplasty which proceeded uneventfully. She was due for dialysis on the 19” December 2013, but due to the very recent surgery she was unable to be transferred out for dialysis treatment at the allotted time. A failure thereafter to appropriately monitor her on the ward and a consequent delay in commencing hemofiltration, contributed to her death. 4 | CIRCUMSTANCES OF THE DEATH 1. Mrs Awa Jeng was admitted to Newham General Hospital in the early hours of the 18"" December 2013 following a fall at her home. She sustained a fracture of the left hip and underwent a necessary surgical procedure during the day on the 18" December 2013. She appeared to recover well from the surgical procedure. 2. Mrs Jeng suffered from a number of medical comorbidities including hypertension, Addison's disease, chronic asthma, type II diabetes and end stage renal failure. She required dialysis three times a week and would attend on a Tuesday, Thursday and Saturday at Whipps Cross Hospital for her treatment. 3. She underwent dialysis at Whipps Cross Hospital on Tuesday the 17" December 2013. Her next dialysis treatment was required whilst she was an inpatient at Newham General Hospital. As she had very recently undergone orthopaedic surgery (hemiarthroplasty) she was not able to be transferred out of the hospital for dialysis. The only option for renal replacement therapy was treatment on the intensive care unit at Newham General Hospital, if her clinical condition required this. 4. She was assessed by the ITU consultant who requested that the ward team observe her for signs of fluid overload, pulmonary oedema, hyperkalaemia or acidemia. This would have required clinical examinations by the medial staff, frequent nursing observations and a repeat of the arterial blood gases. Following this advice by the ITU consultant, there was no further medical review on the 19 December, there were very infrequent nursing observations and the arterial blood gas was not obtained or requested. 5. The following morning at 09.05, the arterial blood gas was repeated and her potassium level was noted to be at a life threatening level. Her general presentation has also significantly deteriorated. 6. Mrs Jeng was transferred to the intensive care unit after midday and hemofiltration commenced. Her consciousness however continued to reduce and intubation was required. During intubation she suffered a cardiac arrest from which she could not be resuscitated. 7. A post mortem examination as carried out which confirmed a cause of death of 1a. Hypertensive heart disease and end stage renal failure and ||. Fracture of the left femur (operation) and asthma. 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. Mrs Jeng was at high risk of suffering life threatening acute renal failure. Her regular dialysis was due on the 19"" December 2013. Bearing in mind the recent trauma and necessary surgery, an acute deterioration in her condition should have been foreseeable. In the circumstances, she required close monitoring. 2. The ITU consultant gave a clear direction to the FY2 on Tayberry Ward during the afternoon of the 19" December 2013 that the arterial blood gases should be repeated that evening and she should be checked for signs of pulmonary oedema and fluid overload. 3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level. 4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her. 5. Mrs Jeng was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations. 6. | note that the Trust's internal investigation raised concerns in relation to the handover of responsibilities and tasks between day and night shifts. There is however currently no clear action to address this concern. 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. YOUR RESPONSE COPIES and PUBLICATION [DATE] Ie. 4.58 rar a You are under a duty to respond to this report within 56 days of the date of this report, namely by the 17 March 2015. |, 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. | have sent_a copy of my report to the Chief Coroner and to the following Interested Persons — es onc his solicitors, Your Rights Solicitors. |_am_also forwarding a copy of the report to the Care Quality Commission and i Director of Public Health). | 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.
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 NHS Trust Barts Health NHS Trust Trust Executive Offices Ground floor, Pathology Block The Royal London Hospital London, E1 2ES Telephone: 020 32460632 www. bartshealth.nhs.uk Coroner Nadia Persaud Senior Coroner Eastern District of London Walthamstow Coroner's Court Queens Road London E17 8QP 06 March 2015 By special delivery Dear Madam Inquest touching the death of Mrs Awa Jeng | write in response to your Regulation 28: Report to Prevent Future Deaths, dated 20 January 2015. The investigation into your concerns regarding the fact that there was a lack of overnight medical review and insufficient nursing observations in the evening and night of 19 December 2013, and your concerns regarding the handover of responsibilities and tasks between day and night shifts, has now been concluded, lam satisfied that this investigation has been sufficiently robust, in that we have scrutinised all relevant records and communicated with appropriate staff to inform our investigation. | write to apprise you of the conclusions of the investigation. During the investigation, senior clinical staff involved were contacted and confirmed that the Trust is implementing a revised early warning score National Early Warning Score (NEWS) and Chronic Respiratory Early Warning Score (CREWS) which once implemented is expected to improve compliance with contacting and escalating assistance with deteriorating patients. This is being implemented at Newham University Hospital imminently, as well as across the Trust. Newham University Hospital has been awarded funding to implement a vital signs monitoring process known as Vitalslink which will transmit Clinical observations to the Electronic Patient Record (EPR) by WI-FI and give real-time feedback to the clinician regarding at risk status and the appropriate action to take. This is currently being piloted at Newham University Hospital with wider roll-out planned once the pilot is approved. Barts Health ; NHS Trust The Vitalslink system will enable remote observation and alert for patients at risk — this can be used by the outreach team, ward managers and interested clinicians to rapidly detect patients even before the ward nurse has called in their concerns. It does not replace the paper records and is intended to provide an additional level of assurance. The use of a standard machine across the site will also contribute to a clearer training plan, there being only one type of machine in common use. During Stepping into the Future Programme (a pan-London NHS initiative to ensure that patient experience and safety is optimal) Newham University. Hospital has refreshed the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift. This includes the introduction of afternoon safety huddles which are open to all staff.and disciplines where issues can be raised and resolved. For clarity, the changes described (above) also apply to Tayberry Ward. Mrs Jeng's death has been discussed at safety briefings on Tayberry Ward. The care and treatment of the deteriorating patient and the appropriate escalation of concerns is also a priority on the ward. Funding has been received for nursing staff to be trained to attain this specific skill set, at London Southbank University. There is a daily consultant led trauma meeting in which all admissions, referrals, patients awaiting trauma surgery, post operative patients from the previous day and any sick patients under the care of the orthopaedic service are discussed, There is a formal list and documentation for this meeting, an action plan for each patient and a record is kept and recorded on the sheet. This document forms the basis for the formal face-to-face handover meeting between the day and night medical teams. Following your Report to Prevent Future Deaths, a section has been added for signing and dating the handover sheet between the member of the team involved and this sheet is retained in the orthopaedic department for audit and transparency purposes. The Trust acknowledges prior difficulties in the orthopaedic department at the time of Mrs Jeng's death, due to shortages of senior staff due to ill health, a death, retirement and dependence on long term locum consultants. Since the beginning of 2014 four new substantive consultants have been appointed and two further locum consultants with a plan to make these posts substantive. One of the new consultants has been appointed as the clinical governance lead for the department. There is better senior engagement with other departments on the Newham site and successful recruitment at the middle grade to stop the reliance on locum doctors, There is now a full complement of middle grade doctors. At the SHO level the Trust continues to actively recruit although this remains a national problem. The Trust surgery Clinic Academic Group (CAG) is currently planning a potential international recruitment drive, which is under consideration by the surgery CAG executive director. Barts Health INHS| NHS Trust Regular, formal, recorded Mortality and Morbidity meetings are held and issues are ranked on severity for their short or long-term harm and appropriate events trigger either a Duty of Candour letter, further discussion, a Datix investigation or a Serious Incident investigation. Instructions verbally and written have been sent to all junior doctors in orthopaedics and orthogeriatrics regarding their responsibilities to add details of any patient requiring review out of hours to the trauma sheet before finishing their shifts. All renal dialysis patients admitted under surgical care are discussed with the renal team as a matter of course. As each of the orthopaedic departments within the Trust has a different structure volume of work and varying information technology, these changes are local and not Trust wide. However, very similar measures are well established and very comprehensive at the Royal London Hospital site, and as a Trust, we are in regular contact with our colleagues at the other Trust sites, to share and learn from each others' practice. 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 edical Director Barts Health NHS Trust
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