Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0178, written 7 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 | 7 May 2015 |
|---|---|
| Reference | 2015-0178 |
| Deceased | Evelyn Kennedy |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) : KAREN HENDERSON, BSC,BM,MRCPI,FRC.. GILVA D.J.TISSHA W, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES 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. Matthew Kershaw, Chief Executive, Brighton & Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton 2. — Chief Nurse, Brighton & Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton | CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 i INVESTIGATION and INQUEST On 7" November 2014 | commenced an investigation into the death of Mrs. Evelyn KENNEDY. The investigation concluded at the end of the inquest on 21° April 2015 .The conclusion of the Inquest was: Mrs. KENNEDY died of hospital acquired pneumonia. Her death was probably accelerated by a short time because of the effects of her 5 day admission to the Acute Medical Unit at The Royal Sussex County Hospital, Brighton. This admission was characterised by suboptimal care in almost every respect. During Mrs. KENNEDY’s stay there were breaches of 5 of the hospital’s own policies which directly affected her. For Mrs. KENNEDY the Acute Medical Unit was chaotic and not fit for purpose. | CIRCUMSTANCES OF THE DEATH Mrs. KENNEDY was a frail 89 year old lady who was living at a Rehabilitation Unit where she had a number of multifactorial minor injury falls. She came to The Royal Sussex County Hospital by ambulance on 14.10.2014 and was admitted to the Acute Medical Unit on 15.10.2014. She remained there until the 20" when a bed was found for her on Bristol Ward, On arrival at Bristol Ward staff raised a Vulnerable Adult Alert. Mrs. KENNEDY remained on the ward until her death on 29" October 2014. VERONICA HAMILTON-DEELEY, LL.B. THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONER’S CONCERNS | i 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) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. ) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band, (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16", 17", 18", 19" or 20°. (14) Care plans were not completed for 17", 18", or 19". (15) Repositioning charts were incomplete or poor for 16", 17'", 48" and 19". (16) The handling assessment was not completed for 16", 18", 19" or 20". (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18" and 19". (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21° October. (29) She should have been specialled, but wasn't. Once again AMU has been found to be chaotic and not fit for purpose. ACTION MUST BE TAKEN In my opinion action must be taken to prevent future deaths and | believe you AND your organisation have the power to take such action. VERONICA HAMILTON-DEELEY, LL.B. THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPIFRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27" July 2015. 1, 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 meer AMU Manager, Brighton & Sussex University Hospitals NHS Trust, inical Commissioning Group Secretary of State for Health, Department of Health Simon Stevens — Chief Executive NHS England National Patient Safety Agency PY Department of Health | have also sent it to:- Doakwn> a Counsel for Brighton and Hove City Council, Craven Vale Resource Centre ; ——__ Craven Vale Resource Centre, a Adult Social Care, Brighton and Hove City Council PORN Who may find it useful or of interest. tam 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. Date: 7" May 2015 Veronica HAMILTON-DEELEY Senior Coroner Brighton andHove
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.
Brighton and Sussex NHS | Your _e. University Hospitals Cur Ref: NHS Trust 24 July 2015 Headquarters The Royal Sussex County Hospital Miss V Hamilton-Deeley Eastern Road HM Coroner Brighton Coroner’s Office, Woodvale BN2 5BE Lewes Road } BRIGHTON Te mz BN2 3QB Dear Miss Hamilton-Deeley The Late Evelyn Kennedy, died 29.10.14 NHS No: 434 604 2457 Thank you for your letter of 7 May 2015 setting out your concerns about the functioning of the Acute Medical Unit. We acknowledge and are sorry that the Acute Medical Unit was struggling to provide effective care at the time of Mrs Kennedy’s admission, despite the best efforts of the Trust to address this, and as |, as Chief Executive, commented at the inquest we deeply regret the consequences of this for Mrs Kennedy’s care. The Acute Medical Unit is one of the areas of the Trust that has faced particular difficulties as the capacity of the hospital remains very pressurised. The increasing acuity of the patients we treat, spikes in admissions and at times the number of people medically ready for discharge but unable to leave the care of the acute hospital for a variety of reasons has also risen. This has led to challenges in timely identification of suitable specialist beds for all those who need them, as well as challenges in ensuring patients awaiting admission are moved promptly from the Emergency Department, and both these factors have had an adverse effect on the Acute Medical Unit. The Trust has been working internally with clinical leaders and closely with our partners in the community to develop creative and effective ways of addressing these issues, and at the same time has been endeavoring to support the staff who are working so hard to provide high quality care on the Acute Medical Unit for all who need it. We acknowledge that in spite of recognition of these issues and considerable efforts over a long period to improve the quality of care provided in the Acute Medical Unit, the care actually provided for Mrs Kennedy, and the documentation of that care fell considerably below the standard we expect for every single patient of this Trust. With our partner Seat brighton and susse * medical school For that as the accountable officer, | (Chief Executive) have already apologised personally to Mrs Kennedy’s family as well as publicly. The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs Kennedy’s last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications. When each shift is fully staffed, it is much easier for the staff on duty both to provide high quality care for each patient and to record this in detail. Trustwide, there has been considerable progress in the last 12 months in the recruitment of nursing staff, even though, as you are no doubt aware, there is a national shortage of skilled nurses and this has made recruitment and retention more challenging. Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include: 1. increasing permanent staffing levels in the area, including both increased input from the matron and appointment of an additional senior nurse to the area as well as introducing a new support assistant role 2. using different methods to assist in obtaining bank and agency staff as necessary to fill vacant shifts 3. appointing a practice educator specifically for the Acute Medical Unit to teach and support staff in the workplace 4. assigning a critical care outreach nurse to work with the Acute Medical Unit, providing a link with critical care services 5. establishing a working group to address a range of practices and documentation to ensure sick patients receive timely and appropriate attention 6. developing specialist areas and associated staffing skills within the Acute Medical Unit for specific groups of cohorts of patient, including those who are particularly sick and those who are confused or suffering dementia 7. improving the signs and layout within the Acute Medical Unit to assist confused patients with orientation within the unit and help them to settle better into the environment 8. improving the quality of information and clinical handover provided for each patient when they are transferred from the Acute Medical Unit to a specialist ward 9. Increased monitoring of documentation, with real-time feedback given to the nurses Extensive and complex work is also being undertaken to 10. Review and condense Acute Medical Unit documentation, making it multi-disciplinary and more useful in directing the right care for each patient. The revised paperwork is intended to facilitate joined up thinking for each patient, to avoid repetition between clinicians, reduce the paperwork burden and free more nursing time for direct care. While this process must proceed slowly and very carefully to ensure that any changes are indeed beneficial for the patients, the first trial of the revised paperwork has recently taken place. It is intended that the revised documentation will be suitable for adaptation to electronic usage once electronic patient records come into use in the area, although this is not imminent. 11. Participate in the FrailSafe national project, in which the Trust is a pilot site. This is intended to improve the care of frail patients. Thank you once again for raising these matters with us. We confirm the Trust remains committed to a continuing programme to address the concerns you describe and to monitor the effectiveness of the changes introduced in resolving these issues. Yours sincerely J- Matthew Kershaw Chief Executive SaTca Nurse
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