Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0053, written 11 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 | 11 Feb 2015 |
|---|---|
| Reference | 2015-0053 |
| Deceased | Rufjan Bibi |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| 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
Rufjan BIBI (died 19.09.14)
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 23 September 2015, I commenced an investigation into the death of
Rufjan Bibi, aged 72 years. The investigation concluded at the end of the
inquest yesterday.
I made a determination that death was the consequence of an accident,
when Rufjan Bibi fell in Mile End Hospital at around 1.45-1.55pm on 1
July 2014 and hit her head, at the time suffering from Parkinson’s
disease.
Her medical cause of death was:
1a bilateral bronchopneumonia
1b acute on chronic subdural haematoma
2 Parkinson’s disease
1
4
CIRCUMSTANCES OF THE DEATH
Ms Bibi was admitted to the Royal London Hospital on 6 June 2014 and
then transferred to Mile End Hospital on 12 June for rehabilitation.
At the time of admission she was already compromised, as a result of her
Parkinson’s and also a fall that she had sustained at the beginning of the
year causing subdural haematoma.
On 1 July, she was seen sitting beside her bed, and was then found on
the floor having sustained a head injury. I recognise that it is impossible
to prevent falls in hospital completely, just as it is impossible to prevent
falls in the community. However, there other matters that I should like to
bring to your attention.
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. Ms Bibi’s family told me at inquest that when they came to visit Ms
Bibi, which they did daily, they often found her in need of changing
(she was incontinent), and then had difficulty obtaining prompt
nurse assistance.
They even found her with faeces in her hair.
Whilst this did not impact upon the outcome, it made me question
the evidence I had been given about frequent nursing contact, in a
way that I would not otherwise have done. (And of course,
however busy staff are, it is not a situation that any of us would
want for our loved ones.)
2. Family members were also unhappy that a nurse had told them
that, if they wanted closer care for Ms Bibi, then they could engage
a nurse privately to come to the hospital to look after her.
If this is seriously being suggested as the way for a patient in an
NHS hospital to receive appropriate care, then it is worrying indeed
for all patients.
If it is not seriously being suggested, then it seems unkind and
unnecessary.
2
3. Having been found at just before 2pm, Ms Bibi did not receive a
consultant review until 7pm, and arrangements were then made for
her transfer to the Royal London Hospital.
During the intervening five hours, she had a Glasgow Coma Score
of ten, yet no witness was able to explain the delay.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 13 April 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
Professor Dame Sally Davies, Chief Medical Officer for England
, granddaughter of Rufjan Bibi
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 find it useful or of 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.
9
DATE SIGNED BY SENIOR CORONER
11.02.15
3
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 Barts Health NHS Trust Trust Executive Offices Ground floor, Pathology Block The Royal London Hospital London, E1 2ES Telephone: www.bartshealth.nhs.uk Ms M E Hassell Senior Coroner for Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 02 April 2015 By special delivery Dear Ms Hassell Inquest touching the death of Mrs Rufjan Bibi | write in response to your Regulation 28: Report to Prevent Future Deaths, dated 11 February 2015. Your first concern was related to the standard of nursing care afforded to Mrs Bibi. The family alleged that Mrs Bibi was often found by them in a state requiring urgent cleaning as she was incontinent. They were unhappy with the speed by which nursing staff gave assistance. This matter was discussed with the family at the Local Resolution Meeting that was held between them and Trust staff. During this meeting the Trust apologised to the family. The Trust found that Mrs Bibi was not able to properly articulate her needs and was suffering from dementia. The communication issues arising from this were a significant contributing factor in the reduced speed of nursing care. Also, the family members did not raise this as an issue to Trust staff at the time on the ward and as such immediate action could not be taken. Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1* and 3 Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to \& ABQy,, Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, g V/s . & The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross University Hospital. lads SAB Barts Health INHS| NHS Trust think about how they would act if they were to encounter the same scenario a second time. Training to staff is being provided as part of the Older Peoples Education Programme. There is also a Band 7 Ward Manager Supervisory role whereby a Band 7 if possible has a reduced patient workload allowing them to offer support and guidance to more junior staff on a range of clinical issues. Your second concern involved a member of Barts Health staff telling the Bibi family that if they wanted closer care for Mrs Bibi that they should engage a nurse privately to come into the hospital and care for her on a 1:1 basis. This was also discussed at the Local Resolution Meeting held between Trust staff and Mrs Bibi’s family. Apologies were made; however, as there were communication issues between Trust staff and the family, the Trust did feel that this was very unlikely to have been said. It is not usual practice to have private 1:1 carers and it is not an option that the Trust would offer. All patients are assessed on admission and regularly reassessed throughout their stay. Mrs Bibi did not meet the Trusts criteria for 1:1 nursing and the staff caring for her at the time used professional judgement to determine if special care was needed for her outside of the written criteria. Your final concern related to the five hour gap between Mrs Bibi’s fall at 2pm and her first consultant review at 7pm. This also was discussed at the Local Resolution Meeting and an apology made to the family. The consultant in charge, doctor as spoken to the junior doctor who was assigned to the ward at that time. They remembered assessing the patient but did not remember documenting the assessment. The medical review was undertaken very soon after the fall as the Medical Team were on the ward when the fall occurred. Nursing documentation supports that a review and appropriate checks were instigated as per Barts Health Post-Falls procedures. The delay in obtaining a consultant review is not usual practice and should not have happened. The member of staff involved has been given training about obtaining a consultant review when a patient is acutely unwell or suffers a potentially dangerous injury. The doctor will also reflect on this incident in their portfolio. HE has also discussed Mrs Bibi’s case at one of the departmental morbidity and mortality meetings prior to the Inquest hearing, the Coroner’s findings will be reported back to the department at the next meeting. has also met with the new trainees who joined the department on the 01 April 2015. She explained the department's escalation policy regarding patients on the rehabilitation site or on any of the wards, who become acutely unwell. Timely assessment and intervention with good documentation are essential in ensuring that acute serious problems are treated appropriately. Senior review should always be sought expeditiously so that on-going management can be planned. Any adverse incidents on the ward, whether resulting in harm or not, should always be discussed and documented with patients and/or relatives as appropriate. Plans for on-going care should be specified. The aim of this training to juniors is to prevent delay in care that is likely to result in harm to our patients. tt Boy, Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, 3 vv is The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital. Barts Health INHS| NHS Trust Thank you for bringing your concerns to my attention. | trust that you are assured | have taken them seriously and investigated them appropriately. Yours faithfully roup Director for Emergency Care and Acute Medicine (ECAM) Barts Health NHS Trust Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew/s Hospital and Whipps Cross University Hospital.
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