Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0190, written 15 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 | 15 May 2015 |
|---|---|
| Reference | 2015-0190 |
| Deceased | Sara Green |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Rotherham Doncaster and South Humber NHS Foundation Trust |
| 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. Mr Tom Riall , Chief Executive Officer, Priory Group, Floor 5, 80 Hammersmith Road, London W14 8UD. 1 | CORONER | am Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South. 2 | 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 | INVESTIGATION and INQUEST On 24th March 2014 an investigation was commenced into the death of Sara Jane Green who died whilst an in-patient at the Cheadle Royal Hospital, Cheadle on 18th March 20104. The investigation concluded with an Inquest held between 7th and 28th April 2015. The conclusion of the inquest was a Narrative Conclusion: On the 17th July 2013 Sara Green was admitted to Cheadle Royal Hospital for in-patient assessment, treatment and management following an overdose of Anadin tablets on 12th July 2013. At the date of Sara's death on 18th March 2014 she had been an in- patient at Cheadle Royal for 9 months, despite having been considered ready for discharge to a community placement at the beginning of October 2013, with no soon prospect of discharge either to hospital or to a community placement closer to home. Sara's prolonged admission was consequent to 1. the inadequate provision of Tier 4 placements within the Humber & Yorkshire area 2. the lack of Tier 3 community placements within the Humber & Yorkshire area 3. a failure by those engaged in Sara's care to properly and expeditiously arrange and or manage Sara's discharge from Cheadle Royal from October 2013 onwards. Sara's continuing admission with no soon prospect of discharge was a contributory factor to her act of self-harm on the evening of 18th March 2014 which ended her life. Medical cause of death 1a) Asphyxia 1b) Ligature Compression of the neck. 4 | CIRCUMSTANCES OF THE DEATH On 17 March 2014 Sara returned to the Orchard Unit, Cheadle Royal Hospital following a period of home leave which commenced on 6 March 2014. Sara was placed on Level 2 observations on five minute intervals. At a ward round on 18 March 2014, at 16:00 hours, the frequency of the Level 2 observations was reduced to 15 minutes, at Sara's request and in accordance with the observation prescription dated 11 March 2014. Level 2:15 observations commenced at 19:00 hours. At about 20:55 - 21:00 hours Sara was found on the floor of her bedroom with the wire spiral binding taken from an A4 pad wrapped around her neck. CPR was commenced and the emergency services summoned. Resuscitation was unsuccessful and Sara was pronounced dead at 22:31 hours. CORONER’S CONCERNS During the course of the evidence it was discovered that the medical staff (not the nursing staff or other healthcare professionals) were not making contemporaneous records of consultations or attendances with Sara. On occasions there were days passing between a consultation and the medical record being completed. Some examples are below: The record of a consultation on 30 January 2014, timed to have taken place at 15:30 hours was not entered until 09:21 hours on 7 February 2014. The record of a consultation that took place on 4 February 2014 was not entered until 7 February 2014, and was not checked for its accuracy until 10 February 2014. The record of a consultation that took place on 25th February 2014 was not entered until 4 March 2014, and was not checked for its accuracy until 10 March 2014, ! was advised that the method of record-keeping employed is that the consultation is dictated and it is then entered into the records by a secretary. In terms of the record being checked for accuracy, the entry is then simply read by the relevant practitioner without any reference to any hand written note, nor hearing the dictation. It was accepted by one of the doctors subscribing to such a practice that this was an unacceptable practice. That such a late entry into the records of a consultation did not comply with the General Medical Council guidelines for 'Good Medical Practice 2013’. 19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards. As | understand one of the purposes of clear, accurate, legible and up-to-date record- keeping is the dissemination of information to others caring for a patient. In circumstances where days may pass before the record of a consultation/assessment is available to others caring for a patient the passing on, or easy availability, of important information will be denied. That, in my view, places patients at risk. The evidence received on this issue at the Inquest suggests that the system of record- making has not changed but that the entry must now be completed within 24 hours of the consultation. In my view that remains an unacceptable period of time and does not comply with the General Medical Council guideline of completing records “as soon as possible afterwards". It was suggested to me that those healthcare professionals accompanying the medical practitioner(s) on ward rounds and at consultations would pass on any important information at a handover. | am not satisfied that dissemination of information in this manner is entirely appropriate, and that it does not adequately compensate for the lack of contemporaneity. 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 MATTER OF CONCERN is as follows. — That a delay, of up to 24 hours, in 'writing up' the record of a medical consultation may result in important information not being available to, or easily accessible to, other healthcare professionals involved in the care of a patient, or give rise to the possibility of a misinterpretation of that information, or of the information being inaccurate, if it is passed on orally while waiting for the entry to be ‘written up’. This gives rise to a risk of harm to the patient. ACTION SHOULD BE TAKEN In my opinion action should be taken to develop a system, and to ensure its operation, such that the making of medical records complies with the GMC guidelines, "You should make records at the same time as the events you are recording or as soon as possible afterwards", which could not possibly be more than 2-3 hours following a consultation, and certainly before the medical practitioner concerned leaves the hospital. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10" July 2015. |, 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. | have also sent it to: a) ara's mother b) Sara's father c) Rotherham and Doncaster and South Humber NHS Foundation Trust d) North Lincolnshire CAMHS e) NHS England (South Yorkshire and Bassettlaw) f) The Health & Safety Executive | 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. [DATE] [SIGNED BY CORONER] 15.05.15 Andrew Bridgman
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.
PRTORY GROUP OF COMPANIES Your reference: Mr Andrew Bridgman Assistant Coroner Coroners Court i Mount Tabor Street Stockport, SK1 3AG By email and by post 10 July 2015 Dear Mr Bridgman Re. Miss Sara Jane Green (deceased) I write to you in response to the Regulation 28 Report to Prevent Future Deaths (PFD) and the cover letter dated Friday, 15 May 2015 that you issued following the Inquest Touching the Death of Miss Sara Green. You have asked that “action Is taken to develop a system, and to ensure its operation, such that the making of medical records complies with the General Medical Council Guidelines: ‘You should make records at the same time as the events you are recording or as soon as possible afterwards’ which could not possibly be more than 2-3 hours following a consultation and certainly before the medical practitioner concerned leaves the hospital.” Current practice I am advised that, as a general rule, the majority of our medical staff at our Healthcare Division sites do in fact take steps to ensure that clinical records are completed during or very soon after the patient consultation. Staff recognise that this is good practice and helps to minimise the risk of relevant information not being passed on and ensures a consistent approach towards the service user’s care and treatment. However, we accept that at Cheadle, certain staff were not adhering to this practice and as a learning organisation, we have reflected on your concerns and have taken the following steps to improve the making of medical notes during or shortly after consultations. Actions Communications Prior to receipt of your PFD report and based on your comments at the inquest, on Tuesday, 12 May 2015 our Group Medical Director, I wrote to the Hospital Medical Directors at all 42 of the Priory Group Healthcare Division hospitals reminding them of the requirement to ensure that service user records were completed during the course of ward rounds, Care Programme Approach review meetings and multi-disciplinary team meetings. This was followed up on Monday, 18 May 2015 by a formal directive from the Healthcare Division Chief Operations Officer, ~ | to all senior managerial staff reminding them of the requirement to ensure contemporaneous record keeping during the course of ward rounds, Care Programme Approach review meetings and multi-disciplinary team meetings. 1 Priory Group, Filth Aoor, 80 Hammersmith Road, Londen, Wi4 BUD Tel: 020 7605 0910 Fax: 020 7605 0911 Info@priorygroup.com www.priorygroup.com Pnory Group Nu. 1 Linvited traxing as the Priory Group, Registered Office: Fifth Hoor, 80 Hammersnith Road, London, W14 SUD. Registered in England No. 07480252. Part of the Priory Group of Companies. PGOL381duty13 PRIORY GROUP OF COMPANIES At the Healthcare Medical Directors’ Meeting hetd on Tuesday, 30 June 2015, staff were further reminded by Group Director of att) of the need to ensure contemporaneous record keeping including in relation to ward rounds, Care Programme Approach review meetings, multi-disciplinary team meetings, individual one-to-one consultations and assessments. A context was given for the directive and those present were reminded of the General Medical Council guidelines. I should add that during the meeting on 30 June 2015, aspects of good practice were identified_and_ shared. An_example_of_good_practice_was_raised_ by one_of the—Medical Directors who told her colleaques of the efficiencies and positive experiences found in response to the clinical record being projected on to a screen and completed with the active involvement of the service user and the multi-disciplinary team during the meeting itself. This action enables the service user to see what is being recorded and thus helps to promote insight and his/her involvement in their care. We will consider how this practice can be rolled out across the Healthcare Division in appropriate cases. Assistive Technology In light of your concerns, we have been reviewing how we can use information technology to enable clinicians and others to update medical records more quickly. As a starting point, tests have been carried out in relation to wi-fi capability, efficiency and security in those clinical meeting rooms across the Healthcare Division where the absence of fixed computer equipment prevents staff updating contemporaneous records during the consultation or shortly afterwards. The purpose of this is to facilitate the use of tablet computers by staff in these rooms. Where connectivity problems were identified these are either fully resolved or will be resolved by Wednesday, 30 September 2015. In addition, a pilot study has been undertaken at two of our hospitals using different types of tablet computers for use in ward rounds, Care Programme Approach review meetings and muiti-disciplinary team meetings. We expect the pilot to complete by the end of this month and depending on the findings and recommendations, where appropriate we will procure any additional equipment that most effectively meets the needs of our staff. We are optimistic that having access to tablet computers should enable staff to load medical records on to the Care Notes clinical record system during or shortly after a consultation. We expect this process to be completed by Wednesday, 30 September 2015. In the meantime, where the current absence of computer access prevents immediate entry of the contemporaneous records, the meetings will continue to be documented within 2-3 hours following a consultation. Monitoring Following the issue of your report, an entry has been made on the Healthcare Division Risk Register to ensure that the required actions are itemised and that a plan is in place to ensure that the actions are completed within the necessary timescales. The register is reviewed on a monthly basis at Healthcare Division Business Review Meetings. We will also continue to monitor how promptly our medical staff are documenting all service user consultations on an ongoing basis. Monitoring is undertaken as part of monthly local governance and audit arrangements. Record keeping is also routinely considered as part of medical supervision and annual appraisal. 2 Prlory Group, Fifth Floor, 80 Hammersmith Road, London, Wi4 SUD Tel 020 7605 0910 Fax: 020 7605 0911 info@prerygraup.com weew priorygroup.com Priory Group No. 1 Limited trading as the Priory Group, Regtered Office: Fifth Fay, 80 Hammnersinath Road, tongon, Wi4 BUD, Registored In England Na, 07480152. Part of the Priory Group of Companies PCOLINIury1 PRTORY GROUP OF COMPANIES I do hope that this response provides you with the assurance that action has already been taken to address your concerns and that there are plans in place to take further action where necessary. I will of course be happy to provide you with a further update if you feel that would be helpful. Yours sincerely, Tom Riall Chief Executive Officer Priory Group 3 Priary Group, Fifth Foor, BO Hammersmith Road, London, Wi4 BUD Jel: 020 7605 0910 Fax: 020 7605 0911 infogpriorygroup.com www priorygroup.com Prary Group No. 1 Lim ted trading as the Priery Group, Registered Office: Fifth Floor, 80 Hammersmith Read, London, W714 £0. Registered in England No. 07480152 Part of Ine Priory Grows of Companies. PGOLIBI/uly1a
See every Prevention of Future Deaths report matching Rotherham Doncaster and South Humber NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.