Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0108, written 23 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 | 23 Mar 2015 |
|---|---|
| Reference | 2015-0108 |
| Deceased | Pamela Pattison |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport Inhs NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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Our ref. AB//CM/PR_letter To HM Coroner P Pattison Your ref. JSP/KN/00238 2014 23 July 2015 H. M. Coroner Greater Manchester South District Coroner’s Court Mount Tabor Mottram Street Stockport SK1 3PA Dear Mr Pollard Re: Pamela Pattison (Deceased) Stockport INHS NHS Foundation Trust Oak House Stepping Hill Hospital Poplar Grove Stockport SK2 7JE Telephone: 0161 483 1010 E-mail: Thank you for your letter dated 18 March 2015 in which you write pursuant to Regulation 28 of the Coroners (Investigation) Regulations 2013 following the inquest into the death of the above named person; we this received by email from your PA on the 18 June 2015. As always, | am grateful to you for highlighting your concerns and for providing me with an opportunity to respond. | shall address each of your concerns in the order in which you raised them: 1. Nurse training on M4 and A11 with regard to dlabetes care was deficient leading to a failure to escalate care appropriately. The issue of nurse training was highlighted in the Patient Safety Investigation into the care of Mrs Pattison and actions were developed which | understand were shared with you at the inquest. One of our most important actions was the internal commissioning of a “Task and Finish Group” whose remit was “to review the current situation regarding diabetes care to effective care for all patients with diabetes in hospital’. This was chaired by Head of Risk and Customer Services, and included senior medical staff, experienced diabetes specialists (both nursing and medical) and senior nurses from across the Trust. | understand the action plan from this group was also shared with you during the inquest. | am now in a positon to update you on the progress of those actions: a. The Trust Training Needs Analysis (TNA) has been amended to include diabetes training as an essential requirement for all nurses and doctors (see below). Medical staff In training ‘On Essentials “On bespoke induction Diabetic Delivered | Covered on Essentials for all. training for on Registered Nurses and POCT training training and and complete eLearning staff thatare | Essentials | Midwives and all APs also to for glucometer complete module for ‘Safe use of Involved In and complete module ‘Safe use of || delivered in work | eLearning insulin’ every three years Diabetes and | eLearning | insulin’ 3 yearly place oroncare j module for ‘Safe y ¥ associated certificate for use of insulin’ Insulin Too! box training by link nursing support every three process nurses - annually staff years Commencing April 2046 Diabetes Bespoke | Hospital and night nurses and NIA management training those undertaking professional Prescribing prescribing management | Diabetes and Insulln nurse prescribing | advanced session | cover Pharmacy N/A Specialist On commencement Registrars on tralning taught including session commencement Insulin On commencement Specialist Registrars on commencement Diabetes Taught by 2. 4, b. An E-Learning module has been purchased by the Trust (one recommended by NHS England) completion of which is included in the TNA. Bespoke training has been delivered to nursing staff on both M4 and A11 in the care of diabetic patients. d. ‘Essentials’ training (that which is mandatory for all staff every three years) now includes a session on diabetes and insulin management. Link Nurses have been identified for each ward and area and they are receiving specialist training to facilitate local training on all wards. f. Bespoke training has been designed for senior nurses at night and out of hours and the process for delivering this is commencing. All medical staff on commencement receive specialist training regarding prescribing of insulin and diabetes management. Cc. Doctors not being aware that they should not omit long standing insulin Ensuring that all doctors are aware of the appropriate management of diabetes has been addressed both by training (see above) and by an improved “Diabetes Microsite” and improved availability of Diabetes Specialist Nurses. No access to specialist outreach nurse on surgical wards Since this incident there has been a merger of community and hospital teams and the appointment of a further Diabetes Specialist Nurse and a Diabetes Practice Educator, who support the whole Trust. The Trust has also implemented an electronic inpatient referral form for patients needing review, which provides a more robust method for all ward areas to request help or support in managing patients with diabetes. A requirement for additional consultant cover for Diabetes An agreement was reached to expand the consultant cover within Diabetes & Endocrinology in July 2014. This subsequently went out to advert but unfortunately we have failed to recruit on several occasions. The Trust therefore approved an agency locum consultant to be brought in whilst we try to recruit to the post. The locum started in February 2015 and the team have now moved to a ‘Consultant of the week’ model, to provide more specialist inpatient time. No plan for sickness cover for the specialist outreach nurse This planned sickness had been identified and the manager recognised the need for additional cover and backfill for this post. A plan had been put in place to commence on the 27th January 2014, which is sadly the day Mrs Pattison died. The plans referred to in point 3 will help ensure that this does not happen again. Lack of equipment and understanding of how to use equipment: a. Ketone dipsticks As discussed at inquest it was apparent that there was some confusion regarding the monitoring of ketones by nursing staff and this issue is now covered in all delivered training, making clear the process for monitoring ketones. b. Cardiac monitors/ward defibrillator Cardiac monitors are available on the diabetes speciality ward. It is accepted that there were none available for the orthopaedic ward; staff on these wards are not trained to interpret the output from a cardiac monitor so the most appropriate course of action would be to transfer those patients requiring cardiac monitoring to a ward where staff are trained to interpret and respond to the output from a cardiac monitor. In this instance the plan was to move Mrs Pattison as soon as possible; unfortunately this was not as timely as | would have hoped. This matter should then have been escalated through the appropriate out of hours’ management structure to ensure that her move was facilitated as soon as possible. Delay in moving the patient to a medical bed when one was required Following investigation into this incident there is no documented evidence of the time that the bed was requested. | can confirm however that during this period there was a high volume of 4 hour breaches partially due to capacity being limited. During this period the bed management team were prioritising Emergency Department (ED) admissions to prevent overcrowding and maintain patient safety within the ED. However the bed management team are aware that they need to balance priority of bed allocation based on clinical needs of all patients regardless of their location and any concerns could have been raised through the appropriate out of hours’ management structure. The Trust is in the process of reviewing its Capacity and Flow Escalation Policy which will reflect the bed allocation prioritisation process. General under resourcing within the Trust for care of patlents with Diabetes As | have mentioned the Trust recognised there were some areas of concern in regard to the management of patients with Diabetes and in response to this commissioned a “Task and Finish” group. This group has met a number of times and a robust and thorough action plan was developed and approved at the Quality Governance Committee. A plan is in place for an audit in relation to the impact of those actions to be undertaken in September and October 2015 the results of which will be shared at Board level through the Quality Assurance Committee. Evidence to date is that there has been a reduction in serious incidents related to patients with diabetes and there is clear evidence of a good uptake of training. | hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if you have any further questions tegarding this matter. a Yours sincerely Ann Bat Chie’ oe
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Stockport NHS Foundation Trust. 1 | CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester 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 3 | INVESTIGATION and INQUEST On 31* January 2014 | commenced an investigation into the death of Pamela Pattison dob 13" May 1944.The investigation concluded on the 17" March 2015 and the conclusion was one of a Narrative Conclusion. The medical cause of death was 1a Aspiration Pneumonia following insertion of naso-gastric tube for nausea and vomiting consequent upon unstable diabetic control. 11. Brittle diabetes with diabetic nephropathy and diabetic neuropathy. Fractured neck of femur. 4 | CIRCUMSTANCES OF THE DEATH On the 6" January 2014 she fell at her home address and broke her hip. She was admitted to Stepping Hill Hospital and was operated on for her fractured femur. She had numerous co-morbidities including Type 1 Diabetes. On the 17" January her insulin doses were intentionally omitted due to mistaken assessment by one of the medical staff. She was cared for by relatively junior medical and nursing staff when in fact she ought to have been cared for in the HDU. As a result her diabetic care was sub-optimal and various failings led to her being nauseous and tending to vomit, leading to her developing aspiration pneumonia. 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. From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type 1 Diabetes seemed to be limited at best. The nurses were unable to say why they had not escalated her care on a number of occasions. 2. ALL the doctors in training need to be aware that they should not omit any dose of ‘long-acting insulin’. The consultant expressed the ‘hope’ that they would know this, but the evidence suggested the contrary. 3. It was evident that the nursing staff on, for example, the surgical wards, did not have any specialist outreach nurse advice on such things as diabetes. 4. There was an obvious need for additional consultant cover for Diabetes. | was told that funding has been put in place to cover this, but as yet no one has been appointed to fulfil this vital role. 5. The specialist outreach Nurse Practitioner for diabetes was booked off sick for one month, and no ‘cover’ was in place to cover his absence. 6. There was either a lack of equipment or a lack of understanding by the staff as to what equipment was needed by them. The staff indicated that they were unable to find ‘ketone dipsticks’, for diabetic urine sampling. | was told that in fact these are unnecessary in that ketone blood tests are now routine. Similarly | was told they could not find any or sufficient cardiac monitors on the ward. Further evidence revealed there are in excess of 240 such monitors in the hospital but the relevant staff seemed unaware of this. They were also unaware that they could have used the ward based defibrillator for the same purpose. 7. There was a considerable delay of approximately 12 hours in moving her to ward A3 after this had been deemed the appropriate place for her to be. No reason for this delay was offered. 8. It was conceded by the ‘Head of Risk’ for the Trust, that there was a general under resourcing within the Trust for the care of patients with Diabetes. 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 18" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons rare 0° of the deceased) . | have also sent it to C.Q.C. who may tind it useful or of interest. | 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 a copy of this report to any person who he believes may find it useful or of interes jay make representations to me, the coroner, at the time of your response, A He release or the publication of your response by the Chief Coroner. 23.3.15 John Pollard, HM Senior Coroner
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