Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0085, written 4 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2015 |
|---|---|
| Reference | 2015-0085 |
| Deceased | Brian Francis |
| Coroner | Sarah-Jane Richards |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. h- REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT [S BEING SENT TO: 1. Chief Coroner 2. Minister for Health, National Assembly for Wales 3. Chief Executive, Abertawe Bro Morgannwg University Health Board 4. Solicitor representing the family of Mr. Brain Francis CORONER | am Sarah-Jane Richards, Assistant Coroner, for the coroner area of Powys, Bridgend and Glamorgan Valleys CORONER'S LEGAL POWERS 1 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 the 17" September, 2014 | commenced an investigation into the death of Mr. Brian Francis. The investigation concluded at the end of the inquest on the 20" February, 2015. The conclusion of the inquest was natural causes. CIRCUMSTANCES OF THE DEATH On the 5" September, 2014 Mr. Francis was admitted to Princess of Wales Hospital via A&E. He had been unwell for 3/4 days prior to admission and treated by his GP for an infection. On admission the presumptive diagnosis was that of chest sepsis and antibiotics were continued. The clerking process upon hospital admission failed on this occasion and Mr. Francis was not seen by the ‘on duty’ Consultant as he should have been. Had Mr. Francis been seen by the Consultant on admission his diagnosis may have been more accurately determined and therapeutic anti-coagulation therapy commenced. instead, Mr. Francis died of a pulmonary embolism the following day. 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) The process of a Consultant's attendance on patient being noted by a ‘tick in the box’ on a paper record failed. The box had been ticked when in fact the patient had not been reviewed by the Consultant. (2) Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action in the area of: > Ensuring patients once ‘clerked’ within emergency medicine have prompt Consultant review. > Notification that the review has occurred to be indicated to Ward staff. > For Community Health Care records to be electronically available to Emergency Medicine Departments 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1" May, 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner, Mr. Mark Drakeford, Minister of Health, National Assembly for Wales; Mr. Paul Roberts, Chief Executive, Abertawe Bro Morgannwg University Health Board; MEN, Chest Consultant who undertook the Stage 2 Mortality Review; and to the Legal Representative of the Francis family. | 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. L re 4'" March 2015 SIGNED; Dr. Sarah-Jane Richards HM Assistant 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.
tf Q: GIG Bwrdd lechyd Prifysgol (~, . | Abertawe Bro Morgannwg KH SD. y NHS University Health Board Eich Cyf Your ref: @ Direct line/Rhif llinell union: Ein Cyf /Our Ref: P| “Email: Dyddiad/Date: 30" April 2015 Dr Sarah-Jane Richards Assistant Coroner Powys, Bridgend and Glamorgan Valleys Rock Grounds First Floor Aberdare CF44 7AE Dear Dr Richards Brian Francis (Deceased) | write further to the Regulation 28 Report you issued following the inquest held on 20" February 2015 where the conclusion was natural causes. Prior to the inquest the Health Board provided you with an action plan which had been implemented following the death of Mr Francis. | have enclosed an updated action plan and have detailed below the Health Board’s response to your concerns that future deaths could result if action is not taken. The Health Board has taken the following actions in the area of: 1. Ensuring patients once “clerked” within emergency medicine have prompt Consultant review. The Quality standards from the Society for Acute Medicine www.acutemedicine.org.uk/index.php?option=com_content&view=article&id=214<emid=90 and Royal College of Physicians acute care toolkit recommendations, www.rcplondon.ac.uk/act2 require all patients to undergo consultant review within 14 hours of arrival. ° Chairman/Cadeirydd: Professor Andrew Davies ° Chief Executive/ Prif Weithredydd: Mr Paul Roberts ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot. SA12 7BR. Telephone: 01639 683344 Ffon 01639 683344 FAX: 01639 687675 and 01639 687676 Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board www.abm.wales.nhs.uk The systems in the Princess of Wales Hospital have been reviewed, in the light of this serious incident and have been enhanced to ensure all emergency medical patients admitted to the hospital are reviewed by a senior clinician or consultant within 14 hours or sooner if clinically indicated. There are two entry points through which patients who may require emergency medical admission come into the hospital: The Acute Medical Unit (AMU) and the Emergency Department (ED). The AMU accepts referrals from General Practitioners and the ED assesses patients who arrive at the hospital independently or via ambulance transportation. Every day there is a consultant physician on call and he/she will carry out two rounds in each 24 hours and be available when called to assess or provide expert opinion on patients that members of his/her junior team feel need to be clinically reviewed. At the two entrances there are two registers one in the ED department and one in the AMU department and these are now formatted the same way and require the consultant to sign the register when he/she has seen the patient (Appendix 1). This enables the nursing and medical teams to see quickly who has been reviewed and by whom and who has yet to be reviewed. This has replaced the tick box that previously existed; recognising that the ticks could have been entered by anyone and the system could not be reviewed and checked. The enclosed map (Appendix 2) shows the Clinical Decision Unit (now called the Acute Medical Unit) and Emergency Department are next to each other and the medical team works in both areas throughout the 24/7 service. We will continue to monitor the system in place and the Clinical Director will review the working practices of the Consultant Physician body in this regard. The Clinical Director has reinforced to all Consultants that it is vital that they only sign the book after a review has taken place and is monitoring the system. All the teams are aware of this incident and inquest and have learned from that. They continue to monitor and review and support the ongoing pilot to develop an electronic system. The Health Board is piloting a live electronic “work list’ which allows medical and surgical teams to be notified of patients that are requiring reviews and decisions about their treatment. Initially the functionality will provide: - A list of patients under a particular consultant's care at any particular time with the ward location (and bay/bed) of each patient - Ahistory of previous entries saved on the work list. - A display to others involved in the care of the patient e.g. nurses with ability to add information (again auditable). - Apprint out and electronic signature of the person inputting the data. - Allentries on the work list will be time stamped and user authenticated by the NHS National Authentication System (NADEX). * Chairman/Cadeirydd: Professor Andrew Davies « Chief Executive/ Prif Weithredydd: Mr Paul Roberts ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot. SA12 7BR. Telephone: 01639 683344 Ffon 01639 683344 FAX: 01639 687675 and 01639 687676 Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board www.abm.wales.nhs.uk From September 2015 a new National Emergency Department system (called Symphony) will be implemented within the Emergency Departments and Assessment Units throughout the Health Board. Initially the system will be introduced in Princess of Wales Hospital and Neath Port Talbot Hospitals in September 2015, the first sites in NHS Wales to go live with the new national system. This will be followed by implementation in Morriston and Singleton Hospitals in November 2015. The Symphony ED system has the ability to request a specialist review of the patient and the time that request was made. The system records the time when the specialist reviews the patient and enables the specialist to record clinical notes to support the review. We have the facility within Symphony to set a target time from "request made" to "review actioned" and the patient will change colour if this time parameter is breached. This information will be available to all Emergency staff and on-call staff. 2. Notification that the review has occurred to be indicated to Ward staff —_—A—'r_raoeenet ie Feview has occurred to be indicated to Ward staff The current arrangements have been reviewed and it is clear that when a patient is admitted the clinical assessment documentation is completed by the admitting doctor. A copy of the document is attached (Appendix 3) and comes as a booklet rather than 8 separate sheets. Page 8 of that document has to be completed by the senior reviewing Clinician. This record is sent to the ward with the patient and so ward staff can quickly identify whether senior review has taken place and the time that it took place. Nursing staff know to seek medical review, if it has not taken place and if the patient’s condition required it. The staff would use the National Early Warning Score (NEWS) to guide their actions when assessing a patient’s need for review. The Chief Nurse has reinforced the importance of nursing staff reviewing the documentation that comes to the ward with the patient as the nurses admit the patient. 3. For Community Health Care records to be electronically available to Emergency Medicine Departments A summary of the GP record is currently available in out-of-hours GP services. This national service is currently being extended for use in hospital emergency settings. Pilot projects are already underway in Cardiff and the Vale and Anuerin Bevan Health Boards and our Health Board has already indicated our eagerness to provide this service locally as soon as the pilot studies have been completed. » Chairman/Cadeirydd: Professor Andrew Davies ° Chief Executive/ Prif Weithredydd: Mr Paul Roberts ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot. SA12 7BR. Telephone: 01639 683344 Ffon 01639 683344 FAX: 01639 687675 and 01639 687676 Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board www.abm.wales.nhs.uk | trust that the actions taken/proposed to be taken by the Health Board addresses the matters of concern raised in the Regulation 28 Report. Please do not hesitate to contact me should you require any further information. Yours sincerely Paul Roberts CHIEF EXECUTIVE Encs. ~ Chairman/Cadeirydd: Professor Andrew Davies « Chief Executive/ Prif Weithredydd: Mr Paul Roberts ABM Headquarters/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot. SA12 7BR. Telephone: 01639 683344 Ffon 01639 683344 FAX: 01639 687675 and 01639 687676 Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgo! Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Lo: www.abm.wales.nhs.uk cal Health Board
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