Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0175, written 1 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2015 |
|---|---|
| Reference | 2015-0175 |
| Deceased | Jayne Jowett |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Community health care and emergency services 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. ies of Partnerships in Care (PIC) 2 Ashfield House Surgery, Annesley Woodhouse CORONER | am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 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. INVESTIGATION and INQUEST On the 29th October 2014, | commenced an investigation into the death of Jayne Jowett, aged 30 years. The investigation concluded at the end of the inquest on 27" March 2015. The conclusion of the inquest was a Narrative as follows: On the 15" September 2014 Ms Jayne Jowett became unwell. She had intermittent but continuing respiratory difficulties, with low oxygen saturations at times in the days prior to her death, She was not taken to hospital for assessment. She died of a pulmonary embolus on the 23” September 2014. | CIRCUMSTANCES OF THE DEATH Ms Jowett was resident at Annesley House, a Partnerships in Care facility, providing low secure and locked rehabilitation mental health care for women. She was detained under section 47/49 of the Mental Health Act 1983. She had a learning disability anda personality disorder. She was on a range of psychotropic medication, and had asthma. She was smoker. From the 15" September 2014 she was unwell with intermittent symptoms of dizziness, breathlessness and episodes of collapse, needing oxygen. She was seen by the doctors and nurses at Annesley House, and by her GP. Her vital signs were monitored using the National Early Warning Score (NEWS) system. Guidelines as to how to respond to rising NEWS were not followed, and no hospital assessment was organised. There were missed opportunities by both Partnerships in Care and by the GP to recognise and respond to her clinical condition in the days prior to her death Following the Hearing | received an additional statement and documents from Partnerships in Care addressing issues that arose during evidence. These documents went some way to addressing concerns raised, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed. 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. PIC Staff Training in National Early Warning Scores: Training in both interpretation of scores, and response to escalation in scores has not to date demonstrated improvement in assessment of a patients clinical condition. The impact of training on patient assessment requires ongoing audit and monitoring. 2. PIC staff at Annesley House have low levels of understanding of the significance of clinical signs such as cyanosis, pallor, breathlessness, and the significance of a patient needing oxygen treatment. There are no plans currently in place to address this 3. There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care. There is no clear guidance that ensures all information regarding a patient's physical condition is communicated to a GP when seeing a patient. 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 the 30 July 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. For the avoidance of doubt, | will require a response from Partnerships in Care to 1) and 2) above, and from the GP and PIC to 3). However, respondents are at liberty and encouraged to respond to all of the issues raised. Respondents may consider it advantageous to consider some of these issues jointly as well as individually. Should respondents favour supplementing their individual responses to all the above issues with a joint response, such a collaborative approach would be greatly welcomed but there is of course no obligation to do so. ‘ COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: a ::-: and Next of Kin) 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. 1 May 2015 Dr E A Didcock
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.
2 inperial Place, Maxwell Road, i me Boreharmwood, Hertfordshire WDE 1UN Pa rtners h I ps In Ca re T. 020 8327 1800 | wwww.parinershipsincare.co.uk Where belter comes together Dr Elizabeth Didcock Assistant Coroner for the Area of Nottinghamshire Nottinghamshire Coroner's Service The Council House Old Market Square Nottingham NGI 2DT : 30 July 2015 Dear Dr Didcock Inquest into the death of Jayne Jowett Response to a Regulation 28 Report 1 write in response to your Regulation 28 Report dated 1 May 2015, I am grateful to you for bringing these matters to my attention as Partnerships in Care (“PIC”) take all patient safety issues very seriously, particularly where there may be lessons to be learnt more widely. Thank you also for the extension of time that you kindly granted to enable us to respond fully, — The death of Jayne Jowett was obviously an extremely sad event and my sympathy goes to everyone who knew her. From the perspective of PIC, if there are lessons to be learnt, we will ensure that these are appropriately addressed. Your Report of 1 May raises three issues pursuant to Regulation 28 to which I will respond in turn. : 1 PIC Staff Training in National Early Warning Scores (“NEWS”): Training in both interpretation of Scores and response to Escalation in Scores has not to date demonstrated improvement in assessment of a patient’s clinical condition. The impact of training on patient assessment requires ongoing audit and monitoring. All nursing staff at relevant sites were trained on the NEWS when this was rolled out originally in 2013, and all qualified staff at those sites have been retrained on this following this inquest. We have now also arranged for this to form part of the induction training so that all new qualified staff will be trained on this as part of their induction to PIC, Additionally, the training is to be refreshed annually, Staff receive an email reminder of the need to do this annual refresher training. Part of the PIC internal audit system includes checking that staff complete their necessary training. Further, the policy and details relating to NEWS are available for staff to access on the PIC intranet so that they can refresh themselves at any time where necessary. gy INVESTORS | Ya IN PEOPLE | © Partnerships in Care Limited is registered in England, no, 02622754 Our values: Registerad Qifigasye? (nmerial Place, Maxwell Road, Boréharwood, Valuing people « Caring safely © Integrity Hertiordshine, WO6 4JN Working together * Quality PIC has reviewed its medical emergencies policy with the assistance of the Group Medical Director and we have placed a physical health NEWS algorithm in each clinic room and ward office at Annesley House. Overview monitoring of the use of NEWS is undertaken by our registered managers as part of their general duties and through corporate clinical governance meetings, which are held monthly. Direct monitoring is undertaken by physical health care issues being a standing agenda item in the morning management meeting at Annesley hospital and anybody who has had any physical health concerns requiring the NEWS to be used will be discussed at that meeting. The successful use of NEWS is evidenced by the fact that patients have been referred to the GP or A & E as a result of the use of this, 2 PIC Staff at Annesley House have low levels of understanding of the significance of clinical signs such as cyanosis, pallor, breathlessness, and the significance of a patient needing oxygen treatment. There are no plans currently in place to address this, The training provided by PIC is extensive. This includes training in Intermediate Life Support (“ILS”) for all doctors, registered nurses, and tutors responsible for training staff in relation to the management of violence and aggression. The ILS training that we provide includes recognition of these -issues, The training providers who deliver this training are all externally accredited to provide training on these matters, and the content of the courses is periodically reviewed by PIC as part of its governance processes. We will also be ensuring that staff are aware of the specific identification of clinical issues that you have raised here through the one to one supervisions in which staff have their clinical practice discussed by a Senior Manager. 3 There remains no clear current Service Level Agreement regarding how best for PIC to work with the local GP Surgery to provide high quality joint care, There is no clear guidance that ensures all information regarding the patient’s physical condition is communicated to a GP when seeing a patient. : Annesley House works closely with the local GP practice at Ashfield House Surgery. I am pleased to say that we have a Service Level Agreement in place and a copy of this is attached. : In your Regulation 28 Report, you indicated that you would find it helpful for both PIC and the GP practice to consider a joint response. 1 am pleased to say that Annesley House has a good working relationship with Ashficld House Surgery, which I believe can only be to the benefit of our residents and will further assist in addressing the issues raised at paragraph 3 above. The efficacy of that working relationship is evidenced by the fact that this response is indeed sent to you as a joint response both on behalf of PIC eld House Surgery. The content of this letter has been expressly approved by to whom your Report was sent on behalf of Partnerships in Care Wiberg batter comes together the surgery. I have signed this letter on behalf of both Respondents which J trust is acceptable. In conclusion, | am grateful to you for bringing these matters to my attention and I hope this letter provides useful information as to how these issues are being addressed. Yours sincerely ; JoyCllamberlain Chief Executive Partnerships in Care Limited For and on behalf of Partnerships in Care Limited and Ashfield House Surgery Partnerships in Care Where balter cones together
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