Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0115, 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 | 2015-0115 |
| Deceased | James Bateley |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sussex Community NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 THIS REPORT IS BEING SENT TO: Paula Head, Chief Executive Sussex Community NHS Trust Sussex Community NHS Trust Brighton General Hospital Elm Grove Brighton BN2 3EW NHS Coastal West Sussex CCG 1 The Causeway Goring-by-Sea West Sussex BN12 6BT lam Penelope Anna Schofield, Senior Coroner, West Sussex CORONER’S LEGAL POWERS | make this report under Para 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 13" June 2014 | commenced an investigation into the death of James Bateley, born on 24" November 2014, being 88 years of age. An Inquest was opened on 13" June 2014 and was concluded on 10" March 2014 CIRCUMSTANCES OF THE DEATH Mr Bateley was admitted to Worthing Hospital on 30" May 2014 as he was medically unwell. Severe pressure sores with necrosis of tissue on buttocks and scrotal area were documented. A safeguarding alert was rajsed due to the severity of these pressure sores. Mr Bateley died on 6" June 2014. A post mortem examination was carried out and the pathologist gave as the course of death:- 1a. Bronchopneumonia & Sepsis 1b. Necrotising Fasciitis 1c. Pressure Wound 2. Ischaemic Heart disease CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise for 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 make this report to you. The MATTERS OF CONCERN are:- During the evidence it became apparent that neither the nursing home, where Mr Bateley was living, nor the Community Nurses, who had been called in to assist in treating Mr Bateley’s pressure sores had ready access to the necessary dressings. There was evidence given that these dressings are not readily available to nursing homes or the Community Nurses who regularly have to treat this type of ailment. The dressings have to be ordered through the GP and we were told that it could take up to 14 days for them to arrive. In Mr Bateley’s case staff had to borrow and make use other resident's dressings. Sadly Mr Bateley was taken into hospital before his dressings arrived. Whilst the absence of these dressing was 5981872.1 unlikely to have contributed directly to Mr Bateley’s death there is concern for others in the future who cannot rely on others to borrow dressing from. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation, can 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 18" May 2015. |, the Coroner, may extent that period. Your response must contain details of action taken or proposed to be taken, setting out the timeline 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 and to the following interested persons: A, 2. 3. Sussex Community NHS Trust Sussex Community NHS Trust 4. NHS Coastal West Sussex CCG | 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 representation to me, the Coroner, at any time of your response about the release or publication of your response by the Chief Coroner DATE: 22 270) [AQ VC ZO] 5 SIGNED: 1 5981872.1
2 responses 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.
NHS Coastal West Sussex Clinical Commissioning Group — \Coastal West Sussex Clinical Commissioning Group Ms Penelope Schofield ; ili 1 The Causeway Senior Coroner 14 MAY 9915 Uf Goring-By-Sea Coroner's Office - LW Worthing West Sussex Record Office Se Ofchard'Street == mesassinmwanamenaren Chichester 7 Tel: 09103 708488 PO19 1DD 5 May 2015 Dear Ms Schofield Re: Inquest into the death of James BATELEY — 10 March 2015 Further to your letter dated 24 March 2015 highlighting matters of concern and the need to investigate the issues raised, we confirm the following: The matter was referred to our Quality Assurance team whereby a representative met with the Head of Medicines Management CWS CCG, Deputy Designated Nurse: Safeguarding Adults, CWS CCG, the Residential Care Home concerned and a representative of the GP Surgery to investigate dressings not being available and the process undertaken by the Community Nurses who regularly have to treat this type of ailment and the delay in the order of such dressings. The timeline of events was as follows: Need for dressings raised 13 May 2014 First order request submitted 28 May 2014* Further request submitted 2 June 2014 First order received 31 May 2015 Second order received 5 June 2015 *This resulted in a 15 day delay in ordering. The action to be taken will be to contact the Deputy Chief Nurse, Sussex Community NHS Trust to investigate fully the reason for delay in ordering, together with application and use of non-prescribed dressings. This action was completed by Friday 1 May 2015. Assurance has been obtained from the Pharmacy used by the Residential Care Home and we are satisfied there was no delay in processing the dressings order. The Residential Care Home have completed a review of their Management of Prescriptions policy to monitor and ensure there will be no further delays for their residents in relation to prescribed dressings. We would like to reaffirm the patient did receive appropriate treatment by the Community Nurses and the delay in the prescription request was not detrimental to the patient's physical health, as the appropriate dressings were used from within the Residential Home’s stock. Yours sincerely Clinical Chief Officer Coastal West Sussex CCG
Sussex Community 'N NHS Trust Private & Confidential Trust Headquarters Penelope A Schofield J Block Senior Coroner Brighton General Hospital Coroner's Office Elm Grove West Sussex Record Office Brighton Orchard Street BN2 3EW Chichester West Sussex Phone: 01273 242292 PO19 1DD Fax: 01273 242217 sc-tr.serviceexperience@nhs.net www.sussexcommunity.nhs.uk 19" May 2015 Dear Ms Schofield Re: Inquest touching the death of James Bately 10 March 2015. Regulation 28 Report to Prevent Future Deaths Further to you issuing a Regulation 28 in conjunction with the above inquest, | am pleased to provide you with a copy of our action plan designed to improve the provision of dressings for our patients. A number of immediate actions have already been taken, namely: e Meeting with the Clinical Commissioning Group to discuss the concerns (CCG) e Implementation of a ‘Stock box/First Dressing’ system e Implementation of an escalation process for delay in a response for dressings supply Longer-term actions to improve this area of service are being discussed with the CCG. Once engagement and agreements are in place an ONPOS, (On-line Non Prescription Ordering Service) will be run in shadow from July for a 6-12 month period with the plan to roll this out in full from January 2016. The immediate actions taken will already ensure that patients receive appropriate dressings at the start of their care, with the longer term issues providing a more ‘seamless’ service for our patients. If you would find it =_ to_have more information on these actions, please do not hesitate to contact on the number above who will arrange for someone to provide this. Page | of 2 Yours sincerely Chief Executive Sussex Community NHS Trust Page 2 of 2
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