Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0124, written 30 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 | 30 Mar 2015 |
|---|---|
| Reference | 2015-0124 |
| Deceased | Andrea Thirkell |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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:
1. County Durham and Darlington NHS Trust, Darlington Memorial Hospital,
Hollyhurst Road, Darlington DL3 6HX
CORONER
lam Andrew Tweddle Senior Coroner, for the coroner area of County Durham and
Darlington
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.
(see attached sheet)
INVESTIGATION and INQUEST
On 3" September 2014 | commenced an investigation into the death of Andrea Jane
Thirkell, aged 51 years. The investigation concluded at the end of the inquest on 27"
March 2015. The conclusion of the inquest was “The effects of a fall”.
CIRCUMSTANCES OF THE DEATH
The deceased had an unwitnessed fall in a nursing home and was taken to hospital.
After an examination she was deemed fit for discharge at 19.25 hours. She did not
leave the department until 23.03. She arrived back at the nursing home at 23.07 and at
23.25 was found to be unresponsive by the nurse at the nursing home at 23.43 an
ambulance arrived at the nursing home and she arrived back at the hospital at 00.16.
She was then found to have a serious head injury, was kept comfortable and died later
that 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) Although considered to be medically fit for discharge at 19.25 hours she did not
leave the department until 23.03 and during that time she was not subject to any
structured form of monitoring or observation although nursing staff may have
seen her during that time. Evidence was given that since this incident staff have
been reminded that patients should be subject to formal observations if there is
a delay in discharge. Although | was told this | am unclear as to whether there
is a formal trust policy in place in this regard.
) The deceased did not leave the department until 23.03. Evidence was given
that it is common for patients to be discharged late on a night either home or to
a care home knowing that there is likely to be nursing care available. The
evidence | heard was that there was no formal trust policy or written guidance
with regard to the issue of late at night discharge and what other factors need to
be taken account of in considering whether it is safe to discharge a patient at
such time and in what circumstances. The evidence was that each senior
doctor will apply his or her own medical discretion and combined with the
pressures on a busy department | am concerned that this could lead to
inconsistent or potentially erroneous decisions being made.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation 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 26" May 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and ing Interested
Persons - Quality Care Commission | have also sent it to who may find 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 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.
30 March 2015
RES
Andrew Tweddle LL.B.
HM Senior Coroner
County Durham and Darlington
SCHEDULE 5 paragraph 7
ACTION TO PREVENT OTHER DEATHS
1)Where—
(a)a senior coroner has been conducting an investigation under this Part into a person's death,
(b)anything revealed by the investigation gives rise to a concern that circumstances creating a risk of
other deaths will occur, or will continue to exist, in the future, and
(c)in the coroner's opinion, action should be taken to prevent the occurrence or continuation of such
circumstances, or to eliminate or reduce the risk of death created by such circumstances,
the coroner must report the matter to a person who the coroner believes may have power to take
such action.
(2)A person to whom a senior coroner makes a report under this paragraph must give the senior
coroner a written response to it.
(3)A copy of a report under this paragraph, and of the response to it, must be sent to the Chief
Coroner.
Regulations 28 and 29
Report on action to prevent other deaths
28.—(1) This regulation applies where a coroner is under a duty under paragraph 7(1) of
Schedule 5 to make a report to prevent other deaths.
(2) In this regulation, a reference to “a report” means a report to prevent other deaths made by
the coroner.
(3) A report may not be made until the coroner has considered all the documents, evidence and
information that in the opinion of the coroner are relevant to the investigation.
(4) The coroner—
(a) must send a copy of the report to the Chief Coroner and every interested person who in
the coroner's opinion should receive it;
(b) must send a copy of the report to the appropriate Local Safeguarding Children Board
(which has the same meaning as in regulation 24(3)) where the coroner believes the
deceased was under the age of 18; and
(c) may send a copy of the report to any other person who the coroner believes may find it
useful or of interest.
(5) On receipt of a report the Chief Coroner may—
(a) publish a copy of the report, or a summary of it, in such manner as the Chief Coroner
thinks fit; and
(b) send a copy of the report to any person who the Chief Coroner believes may find it useful
or of interest.
Response to a report on action to prevent other deaths
29.—(1) This regulation applies where a person is under a duty to give a response to a report to
prevent other deaths made in accordance with paragraph 7(1) of Schedule 5.
(2) In this regulation, a reference to “a report” means a report to prevent other deaths made by
the coroner.
(3) The response to a report must contain—
(a) details of any action that has been taken or which it is proposed will be taken by the
person giving the response or any other person whether in response to the report or
otherwise and set out a timetable of the action taken or proposed to be taken; or
(b) an explanation as to why no action is proposed.
(4) The response must be provided to the coroner who made the report within 56 days of the
date on which the report is sent.
(5) The coroner who made the report may extend the period referred to in paragraph (4) (even if
an application for extension is made after the time for compliance has expired).
(6) On receipt of a response to a report the coroner—
(a) must send a copy of the response to the report to the Chief Coroner;
(b) must send a copy to any interested persons who in the coroner's opinion should receive it;
and
(c) may send a copy of the response to any other person who the coroner believes may find it
useful or of interest.
(7) On receipt of a copy under paragraph (6)(a) the Chief Coroner may—
(a) publish a copy of the response, or a summary of it, in such manner as the Chief Coroner
thinks fit; and (b) send a copy of the response to any person who the Chief Coroner believes may find
it
useful or of interest (other than a person who has been sent a copy of the response under
Paragraph (6)(b) or (c)).
(8) A person giving a response to a report may make written representations to the coroner
about—
(a) the release of the response; or
(b) the publication of the response.
(9) Representations under paragraph (8) must be made to the coroner no later than the time
when the response to the report to prevent other deaths is provided to the coroner under paragraph
(4).
(10) The coroner must pass any representations made under paragraph (8) to the Chief Coroner
who may then consider those representations and decide whether there should be any restrictions
on the release or publication of the response.
27 MAY 2915
NHS Foundation Trust
Executive Conidor
Darlington Memorial Hospital
Hollyhurst Road
Darlington, DL3 6HX
e-mail:
Our Ref: SJ/bce/HMCoroner
26" May 2015
H.M. Coroners Office
PO Box 282
Bishop Auckland
Co Durham
DL14 4FY
Dear Sir,
| am writing to confirm safe receipt of your letter dated 30 March 2015. | am responding to
the content of your letter and specifically those issues mentioned within your report under Regulation
28 of the Coroners Investigations Regulations 2013. The Matters of Concem as you stated:
“Although considered to be medically fit at 19:25 hours she did not leave the department until 23:03
and during that time she was not subject to any form of structured monitoring or observation although
nursing staff may have seen her during that time. Evidence was given that since this incident staff
have been reminded that patients should be subject fo formal observations if there is a delay in
discharge. Although | was fold this | am unclear as to whether there is a formal trust policy in place in
this regard”.
“The deceased did not leave the department until 23:03. Evidence was given that it is common for
patients to be discharged late on a night either home or to a care home knowing that there is likely to
be nursing care available. The evidence that | heard is that there was no formal trust policy or written
guidance with regard to the issue of late at night discharge and what other factors need fo be taken
account of in considering whether it is safe to discharge a patient at such time and in what
circumstances. The evidence was that each senior doctor will apply his or her own medical discretion
and combined with the pressures on a busy department | am concerned that this could lead to
inconsistent or potentially erroneous decisions being made”.
www.cddft.nhs.uk
Chief Executive. Darlington Memorial Hospital, Hollyhurst Road,
Darlington, County Durham DL3 6HX
: County Durham and Darlington NHS)
Aem ay} je 4 noA yyM
; County Durham and Darlington NHS;
NHS Foundation Trust
The issue you have raised was discussed at the Emergency Department senior staff meeting at the
University Hospital North Durham which convened on 23 April 2015 and was subsequently discussed
and agreed by the Emergency Department at Darlington Memorial Hospital. The consensus of opinion
was that at the time of leaving the department it would have been sensible for a member of the team
to have undertaken a set of observations on the patient, to act upon these if necessary as per the
Early Waming Score (EWS) protoco! and then to record these in the allotted field on Symphony (the
Emergency Department electronic notes system). In addition there is also a field in Symphony, under
the transport Data Entry Protecol (DEP), which the team member is able to utilise to record the name
of the person to whom the patient is retuming. Recording this information in the transport DEP will
ensure that the Emergency Department team member has evidence that there is (when necessary) a
responsible adult at the patient's residence who can take responsibility for the patient's safety and
wellbeing.
This change in practice will be implemented immediately. Amendments have also been made to the
Trusts ‘Going Home Policy’ (POL/NG/0005A), to reflect the discharge procedure from the Emergency
Department including discharges after 22.00 hours. This was discussed and approved at the Trust's
Executive Clinical Lead meeting on 21st May 2015 and will be discussed at the Quality and
Healthcare Governance meeting in June 2015. The change in practice will be implemented
immediately and audited as part of the routine Symphony records audit in which three sets of notes
are audited daily for completeness.
These changes will be implemented across both Darlington and Durham Emergency Departments
following approval.
Yours sincerely
DEPUTY CHIEF EXECUTIVE / EXECUTIVE DIRECTOR OF OPERATIONS
www.cddft.nhs.uk
Chief Executive. Darlington Memorial Hospital, Hollyhurst Road,
Darlington, County Durham DL3 6HX
Aen au} {je g noA YAN
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