Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0051, written 10 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2015 |
|---|---|
| Reference | 2015-0051 |
| Deceased | Jane Robinson |
| Coroner | Catherine Mason |
| Coroner area | Leicester (City & South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS Trust |
| 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.
for Leicester (City and South) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT |S BEING SENT TO: Mr J Adler, Chief Executive, University Hospitals Leicester CORONER | am Mrs Catherine Mason, Senior Coroner for Leicester (City and South) 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/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 08/05/2014 | commenced an investigation into the death of Jane Helen Robinson, 55 . The investigation concluded at the end of the inquest on 10 February 2015. The conclusion of the inquest was Natural causes. Jane Robinson was known to have alcoholic liver disease with ascites and was admitted to the Leicester Royal Infirmary on the 16th April 2014 with shortness of breath. Despite treatment she died on the 4th May 2014 at the hospital. At the time it was believed that she had died from sepsis due to spontaneous bacterial peritonitis. However, no positive evidence of sepsis was found at the post mortem examination and there was no positive microbiology in life. The cause of her death was found to be 1a) Systemic inflammatory response syndrome 1b) Decompensated hepatic failure 1c) Hepatic cirrhosis 1d) Alcoholic liver disease and hepatitis C infection. Therefore, although she was not observed in accordance with her needs, this shortfall in her care did not contribute to her death. CIRCUMSTANCES OF THE DEATH Miss Robinson was known to have alcoholic liver disease with ascites and recent admissions to hospital with hepatic encephalopathy and ascites. She was then re-admitted with shortness of breath on the 16” April 2014 and had a transjugular intra hepatic portasystemic shunt (TIPS) on the 30” April 2014. After the TIPS procedure she developed an increased white cell count and deteriorating coagulation. It was thought that she was suffering from spontaneous bacterial peritonitis. Her condition continued to deteriorate and she died on the 4" May 2014. 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) Basic observations repeatedly not being recorded (2) No evidence of on-going senior review on each shift whereby shortfalls in observations would be detected at an early stage (3) Lack of written decision making rational in relation to the frequency of observation (4) No evidence of any reporting system of healthcare professionals that do not practice in accordance with accepted standards and no evidence of support given to those who do report. ‘Town Hall Square, Leicester, LE! 9BG ‘Tel 0116 4541030 | x O116 225 2537 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 07 April 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 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (sister and brother-in-law) 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. Town Hall Square, Leicester, LEL 9BG Tel 0116 4541030 | Fax 0116 228 2537 Record of Inquest Following an investigation commenced on the 8th day of May 2014 And Inquest opened on the 17th day of November 2014; At an inquest hearing at Leicester Coroners Court on the 10th day of February 2015 heard before Mrs. C.E. Mason Senior Coroner in the coroner's area for Leicester (City and South), the following findings and determinations were made: 1. Name of Deceased (if known) Jane Helen ROBINSON 2. Medical cause of death Systemic inflammatory response syndrome. b Decompensated hepatic failure c Hepatic cirrhosis 1d) Alcoholic liver disease and hepatitis C infection 3. How, when and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death Jane Robinson was known to have alcoholic liver disease with ascites and was admitted to the Leicester Royal Infirmary on the 16th April 2014 with shortness of breath. Despite treatment she died on the 4th May 2014 at the hospital due to systemic inflammatory response syndrome as a natural consequence of decompensated hepatic failure resulting from cirrhosis of the liver, Clinically it was thought that she had died from sepsis but no positive evidence has been found to support this. Therefore, although she was not observed in accordance with her needs, this shortfall in her care did not contribute to her death. rs . Conclusion of the Coroner as to the death Natural causes. 5. Further particulars required by the Births and Death Registration Act 1953 to be registered concerning the death (a) Date and place of birth 22 November 1958 Barnsley Yorkshire (b) Name and Surname of deceased Jane Helen ROBINSON (c) Sex (d) Maiden surname of woman who has married Female (c) Date and place of death Fourth May 2014 Leicester Royal Infirmary, Infirmary Square, Leicester (1) Occupation and usual address 111 Leopold Street, Loughb Signature of Senior Coronet Mrs, C.E. Mason
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.
University Hospitals of Leicester NHS} NHS Trust Ca ring of is pest TIVE'’S OFFICE Leicester Royal Infirmary Level 3 — Chief Executive's Corridor Balmoral Building 7® April 2015 Infirmary Square Leicester LE1 SWW Mrs C Mason HM Coroner The Coroner's Court Town Hall Town Hall Square Leicester LE1 9BG Dear Mrs Mason Jane Robinson | write further to your Regulation 28 report sent to us on 12 February 2015, and am now ina position to respond. | note that the matters of concern are as follows:- Basic observations were repeatedly unrecorded. No evidence of ongoing senior review on each shift whereby shortfalls in observations would be detected at an early stage. Lack of written decision-making rationale in relation to the frequency of observations. No evidence of any reporting system of healthcare professionals. Pe NS Taking your concerns in turn: 14. More frequent observations including recording of the respiratory rate should have occurred in this case which would have given an accurate Early Warning Score (EWS) and prompted escalation. Currently all Health Care Assistants (HCAs) complete a vital signs workbook as part of their induction programme. Work has begun to introduce and embed a competency assessment for HCAs. This work will be led by the Acute Response Team Lead supported by Education and Practice and CMG Heads of Nursing and will be completed by the end of October 2015. Newly Registered Nurses (including International Nurses) have a session on ‘Managing the Deteriorating Patient’ as part of their preceptorship /induction programme. Additionally Sepsis management is part of the Safety Improvement work within the Trust and both nursing and medical staff are undergoing training. The Trust is moving towards recording all observations electronically and the software purchased will automatically calculate the EWS score and send the appropriate alerts. This software package has been programmed to ensure all observation fields, which includes respiration rate, are mandatory requirements. A pilot will be commencing in June 2015 and is then expected to be rolled out across the Trust throughout the following year. This work will be led by an Assistant Chief Nurse and is expected to be concluded by the end of 2016. 2. There was no evidence that the nurse in charge was aware that Mrs Robinson's observations were not being taken appropriately. Work has taken place to improve both the daily Board Round and also the clinical handover process. As part of this work we have strengthened the role of the named nurse, Review of all patients’ observation charts will now take place at the time of clinical University Hospitals of Leloester NHS Trust includes 1 Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www.uhi-tr.nhs.uk Chairman Mr Karamjit Singh Chief Executive Mr John Adier handover by the senior nurse to ensure observations have been taken, recorded accurately and escalated appropriately. The software previously described will allow nurses to record patient observations electronically using mobile devices. This process is fully auditable. 3. In this case Staff regrettably failed to complete the required documentation and follow the instructions which are written on the EWS charts, There Is clear guidance on the current Early Waming Score (EWS) charts for staff to follow when EWS scores have been calculated and actions taken should be recorded on the back of this chart. Ensuring that this is completed is now part of the check at clinical handover time by the named responsible qualified nurse. As Indicated above the Trust has purchased software to record patient observations using mobile technology. The respiration rate is a mandatory field. The software automatically calculates the EWS score and alerts are set to be sent automatically when appropriate. This provides a fully auditable system. 4. |can confirm that there is a reporting system for healthcare professionals when we have concerns about the standard of their practise. Improving Performance and Capability Policy and The Disciplinary policy are in place and used when appropriate with referrals made to professional bodies when necessary. | trust that this response provides you with the assurance that you seek. If you have any further concerns please do not hesitate to contact me. Yours sincerely John Adler Chief Executive University Hospitals of Leicester NHS Trust includes 2 Glenfieid Hospital, Leicester General Hospital and Leicester Royal Infimary Website: www.uhl-tr.nhs.uk Chairman Mr Karamjit Singh Chief Executive Mr John Adier
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