Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0139, written 16 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2015 |
|---|---|
| Reference | 2015-0139 |
| Deceased | Jeanne Summers |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Calderdale and Huddersfield NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Owen Williams, Chief Executive, Calderdale and Huddersfield NHS
Foundation Trust
2.
3.
CORONER
1
I am MARY BURKE, Assistant Coroner for the coroner area of WestYorkshire (Western)
2
CORONER’S LEGAL POWERS
I 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 30 July 2013 I commenced an investigation into the death of Jeanne Elsie Summers,
aged 78 years. The investigation concluded at the end of the inquest on 3rd and 4th
March 2015. At the conclusion of the inquest the medical cause of death was
established as 1(a) Bronchopneumonia and 11. Immobility due to fracture of right ankle
(operated) and Chronic Obstructive Pulmonary Disease and the narrative conclusion
was: “On 14 July 2013, whilst a patient at Huddersfield Royal Infirmary, Jeanne Elsie
Summers suffered an unwitnessed fall which it is likely could have been prevented. As
a result she suffered a fracture to her right ankle which required surgery, following which
she had a period of worsening immobility which is likely to have contributed to the
development of bronchopneumonia which led to her death on 24 July 2013.”
4
CIRCUMSTANCES OF THE DEATH
On the 29th June 2013 Mrs. Summers was admitted to Huddersfield Royal Infirmary with
an exacerbation of her Chronic Obstructive Pulmonary Disease, together with infection.
Mrs Summers was commenced on intravenous antibiotic medication and began to show
signs of improvement. By the 6th July 2013 she was thought well enough to be
discharged home, although there appears to have been no assessment of Mrs.
Summers’ mobility levels at the time of discharge.
The following day, the 7th July 2013, Mrs. Summers was readmitted as she was unable
to mobilise at home and was unable to get out of bed. Following further admission on
the 7th July she was queried to be suffering from pneumonia and/or a urinary tract
infection and she once again commenced intravenous antibiotics. She subsequently
showed signs of slow but gradual improvement.
Shortly after midnight on the 14th July 2013 she was using a zimmer frame to mobilise to
the toilet, supervised by members of staff. Following arrival at the toilet she suffered an
unwitnessed fall in the toilet cubicle. As result she suffered an open fracture to her right
ankle, which required surgical intervention.
Mrs. Summers subsequently developed pneumonia, which was treated with antibiotic
medication. Unfortunately Mrs. Summers did not respond. Her condition continued to
deteriorate and her death was confirmed at 0250 hours on the 24th July 2013 on Ward 5
at Huddersfield Royal Infirmary.
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) The assessment review of Mrs. Summers’ ability prior to her discharge on the
6th July 2013. There is no clear indication that an assessment had been undertaken
prior to Mrs. Summers’ discharge on the 6th July 2013. Her condition was such that she
required further readmission on the 7th July 2013.
(2) During the further readmission on the 7th July 2013 Mrs. Summers was reviewed on
Clinical
a number of occasions by a physiotherapist. At the inquest
Lead Physiotherapist, provided evidence and indicated that the physiotherapy written
records did not provide a full record of all relevant details. These notes are reviewed by
nursing staff in order to ensure the patient’s safe mobilisation and the preparation of
appropriate care plans. I would ask you to consider that additional training and/or
direction should be given to the Physiotherapy Department in order to ensure that a full
record of all relevant details are made within patients’ records.
(3) From the evidence presented at the inquest it appears that at the time when Mrs.
Summers was mobilising in the early hours of the 14th July 2013 she was wearing her
own “fluffy socks”. These were not slipper socks. She was clearly not wearing slippers
at the time. In addition the health care assistant who was supervising Mrs Summers did
not ensure that Mrs. Summers was seated on the toilet within the toilet cubicle before he
left her.
I would request you to consider training and guidance to nursing staff to ensure that,
firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to
provide training guidance to staff of safe systems of transfer to ensure that patients are
not left whilst in the process of transfer.
(4) At the inquest Matron
she undertook in respect of the circumstances surrounding Mrs. Summers’ fall. Matron
indicated in her evidence that she had not received full training with regard
gave evidence in respect of an investigation which
to undertaking an investigation and preparing an investigative report.
Although in her report she stated that one of the objectives was to consider if the fall
could have been prevented, that question was not addressed in her report. When
questioned by me she confirmed in evidence that the socks which Mrs. Summers was
wearing at the time of her fall and the fact that she was left before she had effectively
safely transferred on to the toilet are likely to have been factors which would have
caused, or significantly contributed to Mrs. Summers’ fall. Neither of these points were
identified in the report. I would request that in future all investigators receive the
appropriate training to enable them to undertake a full and appropriate investigation.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe 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.
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 Chief Coroner and to the following Interested
Persons:
who may find it useful or of interest.
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 coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
16th April 2015
M. T. Burke, Assistant Coroner
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