Frederick White

The Dudley Group NHS

NHS Foundation Trust

Black Country Coroner's District

in the matter of Mr Frederick White

HI

Response to Regulation 28 Report to Prevent Future Deaths

The Dudley Group NHS Foundation Trust makes this submission in response to a
Regulation 28 Report to Prevent Future Deaths issued by the Senior Coroner for the
Black County following the inquest into the death of Mr Frederick White held on 28"
May 2015.

. Facts

The facts are set out in the Rule 28, ‘Report to Prevent Future Deaths’ (section 4).

The following issues have been raised by H.M. Coroner

Spinal injuries are relatively uncommon but have the potential to cause significant
morbidity and mortality if not managed effectively. Mr White was an elderly patient
who was at risk of falling and during the course of the inquest evidence emerged
showing that he had sustained a traumatic injury of significant blunt force trauma. He
also gave a description of feelings of numbness and lack of sensation in his legs and
there was also a drop in blood pressure, which should have prompted a conservative
approach in treating the patient by applying immobilisation on suspicion of spinal
cord injury during his initial examination and assessment.

Evidence emerging from the inquest suggested that the initial faiture to immobilise
the patient then continued when he arrived at hospital and the triage process failed to
adequately assess the risk again it appears the triage process is heavily reliant upon
the handover from the paramedic crew without further and detailed assessment.

it wasn’t until five hours after the initial fall that a suspected spinal cord injury was

diagnosed.

in tight of the inquest findings, you May consider that the quidelines and policy in the
assessment and management of actual and potential spinal injuries my need to be

examined.

4. Outcome of internal Investigation & Root Cause Analysis

An internal investigation was undertaken following the inquest and concluded 19
June 2015. The investigation was led by an Executive Director and conducted by
senior medical and nursing staff from the Emergency Department and the Trusts’

Governance Department. The investigation noted that:

e Current triage assessment does not specifically require a grip test. In this incident
there is no documentation suggesting that the patient had neck pain or any
neurological deficiency. The department recognises that the use of a simple grip test,
currently not routinely used by the triage nurses, could be beneficial in identifying

neurology where there is a history of a fall.

* The Emergency Department was operating at full capacity when the patient arrived,
as noted by the Coroner; the patient was seen 2h 41min post admission by a doctor.
The Trust aims to see patients of this type within 1 hour and also aims to have senior
(middle grade and consultant) medical staff to be able to provide a ‘Rapid
Assessment’ of all ambulance-borne patients at arrival.

* There was a 1h 38min delay in getting to CT and a 1h 51min delay in getting the
report. The Trust aims to have CT within 1 hour and a report within 1 hour.

Although the investigation concluded that spinal cord injuries are uncommon and even if
the patient had been immobilised and diagnosed earlier, the patient would not have
survived. Irrespective of this there are actions which the Trust will take to prevent

incidents of this nature in future.

5. Actions to Prevent Future Deaths

The following actions together address H.M Coroner's concerns |-V above:

Date Action

Agreed Recommendatio

in Actions Required

By whom

30 Mar 2015

Debriefing of all staff
involved in the incident

Medical and Nursing
supervisors to debrief relevant
staff members

Consultant ED
Consultant ED2
Sister ED

19 Jun 2015

head injury

Raise awareness of
possible neck injury in
elderly patients with

Inclusion in ED Governance
newsletter sent to all present
and future staff

Discussion at Middle Grade
teaching programme

Discussion at Weekly
Management meeting

Discussion at Quarterly
Governance meeting

Consultant ED2 | In
Consultant ED2 | Progress
Consultant ED2
Consultant ED2

19 Jun 2015 | Reinforce the need

maintain

spinal imaging has
been reported

immobilisation until all

inclusion in ED Governance
newsletter sent to all present
and future staff

to

Discussion at Middle Grade
teaching programme

Consultant ED2 In

Consultant ED2 |

19 Jun 2015 | Triage nurse

assessment includ

patients with head
injury

the test grip in elderly

Review of triage nurse training
Programme to include
requirement for grip

es

1 Senior Clinical In

assessment in specific patients

Nurse Specialist

19 Jun 2015 | Consider the

consultant for
ambulance borne
Patients.

possibility of initiating
a Rapid Assessment
by ED middle grade or

Formal development of a
business case and risk
assessment to support
Provision of a Medical Rapid
Assessment service for all
patients presenting via
ambulance

Clinical Director
Urgent Care

02/07/2015 Compliance with

Future Deaths

Coroners Regulation
28 Report to Prevent

Present the Report to Prevent
Future Deaths at the Divisional

action plan to response to be
with the coroner by 29/07/2015

Divisional

Governance Meeting and agree

Governance Lead

6. Review of Actions

As the subject of a formal Trust investigation the Action Plan will be reviewed under the

Serious Incidents Process. All actions will be reviewed and approved by the Clinical

Quality, Safety & Patient Experience Board Sub-Committee by the end of Quarter 3, in

December.

eas

West Midlands Ambulance Service

NHS Foundation Trust

Report on response to a Regulation 28 report to prevent future deaths issued by Mr
Zafar Siddique the Senior Coroner for the coroner area of Black Country

Background

On 9 April 2015, Mr Zafar Siddique commenced an investigation into the death of Mr
Frederick White.

The investigation concluded at the end of the inquest on 28 May 2015. The conclusion of the
inquest was a narrative conclusion:

Mr White sustained a fall on the 29 March 2015 which caused a traumatic spinal cord injury.
There were failures in recognising his symptoms when paramedics arrived at the scene and
failures to properly immobilise him using a cervical spine collar. There were also further
failures in his care when he arrived at Russells Hall Hospital during further assessment and
immobilisation. Overall | am satisfied on the balance of probability that these collective
failures more than minimally, trivially or negligibly contributed to his death.

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) Spinal injuries are relatively uncommon but have the potential to cause significant
morbidity and mortality if not managed effectively. Mr White was an elderly patient who was
at risk of falling and during the course of the inquest evidence emerged showing that he had
sustained a traumatic injury of significant blunt force trauma. He also gave a description of
feelings of numbness and lack of sensation in his legs and there was also a drop in blood
pressure, which should have prompted a conservative approach in treating the patient by
applying immobilisation on suspicion of spinal cord injury during his initial examination and
assessment.

(2) Evidence emerging from the inquest suggested that the initial failure to immobilise the
patient then continued when he arrived at Hospital and the triage process failed to
adequately assess the risk again it appears the triage process is heavily reliant upon the
handover from the paramedic crew without further and detailed assessment.

(3) It wasn’t until five hours after the initial fail that a suspected spinal cord injury was
diagnosed.

(4) In light of the inquest findings, you may consider that the guidelines and policy on the
assessment and management of actual and potential spinal injuries may need to be
examined.

Overview of West Midlands Regional Trauma System

The West Midlands covers a mixed urban and rural population of 5 million people. Within the
region are the Metropolitan area of Birmingham (population 1.1million) and the large cities of
Coventry (population 320,000) and Stoke-on-Trent (population 250,000) as well as relatively
isolated, rural areas in certain parts.

The Regional Trauma System in the West Midlands went live on the 26" of March 2012. The
planning for this was a lengthy, complex process which has led to a Regional Trauma Care
System that we can truly be proud of. It has resulted in four Major Trauma Centres, with a
network of supporting Trauma Unit hospitals established across the region.

WMASFT has been a major stakeholder in the planning and implementation of this system.
This has included setting up a dedicated trauma desk in our control room staffed by
experienced Critical Care Paramedics. In addition a doctor led helicopter team in the day
has been supplemented by a night time doctor led car team that results in 24 hour support at
major trauma cases. This team is called ECT/MERIT.

The Regional Trauma System consists of three trauma care networks with a major trauma
centre at the heart of each network. The major trauma centres are supported by trauma
units, local emergency hospitals and specialist rehabilitation hospitals. Three trauma care
networks have been set up in the West Midlands. Each network has an adult major trauma
centre at its heart plus the Birmingham Children’s Hospital which is the regional major
trauma centre for children.

Governance for the system is robust with well-established monthly MTC network boards
supported by a regional Trauma Network Office, a regular Performance and Quality Group
and an innovative Trauma Issues Database reporting system to ensure openness and the
prompt resolution of issues.

The Major Trauma Triage Tool

All WMASFT clinicians have received training in the use of a trauma triage tool that is used
to identify major trauma patients, these patients are now taken directly to a Major Trauma
Centre (MTC) following discussion with the Regional Trauma Desk (RTD) if the journey can
be made within 45 minutes. If the journey time to MTC is greater than 45 minutes the patient
can be taken to a supporting Trauma Unit (TU) for optimisation prior to being transferred to
an MTC. The ECT/MERIT team can facilitate this transfer.

Patients who trigger the tool outside of a 45 minute zone will be taken to the nearest Trauma
Unit (TU) and then transferred on to the MTC.

The RTD will make decisions in conjunction with the Medical Emergency Response
intervention Team (MERIT) Doctor and the MTCs on a case by case basis. This means that
on occasions, patients outside of the 45 minute zone may be taken direct to the MTC. The
MERIT team will also be available to provide assistance on scene, intercept en route or to
facilitate a transfer.

The entry criterion for the tool is a judgement by the clinician that the patient has suffered
significant trauma.

Major Trauma Triage Tool

teri P West Midlands Ambulance Service WU
Entry criteria for this triage is a judgement that the popes
patient may have sutfered significant trauma

|

1, Measure 2. Assess anatomy 3. Assess mechanism =} ua Special ‘
vital signs of injury of injury | conditions i j
* Glasgow Coma Scaie s13 + Falls i * Older adutts io
+ Systolic Blood pressure - Adults: >20 feet (one storey} > ~ Risk of injury/death incraases i
(mmHg) <80 mmHg 6 equal to 10 foet) after age 55 years
+ Respiratory Rate <10 oF > - Children: > 10 feet or two | ~ SBP <110 might represent |
29 braatha per minute (<20 or three times the height of} shock after age 66 years
ininfant aged <1 yeaa, the child \) ~ Low impact machaniams
need for ventilatory support (8.9. ground level falls) might
+ High-risk motor . reguit in severa injury j
vehicle collision Secnaeen “
- Intrusion inciuding root: > Sereda
12 inches occupant site rat rentially to
- Ejection (partial or capable trauma es :
Complete} from automobile + Anticoaguionts and bleeding
- Daath in same passenger digorders:
compartment A
- Pi head
~ Vehicle telemetry data are ar righ wok for rap
consistent with a high risk deteroration
of injury | + Burns
* Motor vehicle vs pedestrian’ - Without other trauma
bicyclist thrown, run over. or ere cosinides age
with significant (> 20: mphy i beets aes ssid mag
i : With trauma mechanism: end
ne - Wil “ i
= Motoroycte.craaty > 20 mph tage to major trauma centre |}
* Pregnancy > 20 weeks |
© Clinician judgement in tiaison | |
with RTD }o4
" of the factors anv ee, H
EOC Regional Troume Desk aul aii
for advice Mt any of
Wf af factor the factors:
are present
contact:
EOC Regional
Trouma
for advice

ARP Talkgroup 282 ee Se |
01384 215695 - RTD Emergency Contact | 01384 215696 - RTD General Enquiries | 01384 215697 - RTD Hospital Line

WMASFT uses a version of a triage tool based upon the American College of Surgeon's
Field Triage Guide and has recently revised its triage tool to include the most recent
recommendations from the American Department of Health and Human Services Centre for
Disease Control and Prevention, these recommendations are reproduced below:

Guidelines for Field Triage of Injured Patients
Recommendations of the National Expert Panel on Field Triage, 2011

On arrival at the scene of an injury, the EMS provider must determine the severity of injury,
initiate management of the patient's injuries, and decide the most appropriate destination
hospital for the individual patient. These destination decisions are made through a process
known as “field triage,” which involves an assessment not only of the physiology and
anatomy of injury but also of the mechanism of the injury and special patient and system
considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-
COT) has provided guidance for the field triage process through its “Field Triage Decision
Scheme.”

Older Adults: Criterion Modified

This criterion was modified to include statements that recognize that a SBP <110 might
represent shock after age 65 years and that low-impact mechanisms (e.g., ground-level falls)
might result in severe injury. The Panel recognized that adults aged >65 years are not
transported consistently to the hospital best equipped to manage their injuries (high rates of
under triage relative to other age groups). A retrospective analysis of 10 years of
prospectively collected data in the Maryland Ambulance Information System identified a
higher under triage rate for patients aged 265 years compared with those aged <65 years
(49.9% and 17.8%, respectively; p<0.001). On subsequent multivariate analysis, the authors
noted a decrease in transport to trauma centres for older patients beginning at age 50 years
(OR = 0.67; 95% Cl = 0.57-0.77), with a second decrease at age 70 years (OR = 0.45; 95%
Cl = 0.39-0.53) compared with those patients aged <50 years. In a 4-year retrospective
study of 13,820 patients in the Washington State Trauma Registry, those patients aged >65
years were less likely than those aged <65 years to have had the prehospital system or the
trauma team activated. In addition, use of multivariate logistic regression indicated that
physiologic triage variables (e.g., blood pressure and heart rate) were unreliable predictors
of mortality or interventions in the hospital.

Several studies suggest that differences in the physiologic response to injury and high-risk
mechanisms in older adults might partly explain under triage rates in this age group. In a
retrospective chart review of 2,194 geriatric patients (aged 265 years) at a Level 1 trauma
centre, mortality was noted to increase at a SBP of <110 mmHg. A retrospective review of
106 patients aged >65 years at a Level Il trauma centre indicated that occult hypotension
(Le., decreased perfusion that is not evident by standard vital sign criteria) was present in
42% of patients with “normal” vital signs.

in addition, the Panel reviewed literature that indicated that older adults might be severely
injured in low-energy events (e.g., ground-level falls). An analysis of deaths reported by the
King County Medical Examiner's Office (King County, Washington) indicated that ground
level falls accounted for 237 (34.6%) of all deaths (684) in patients aged 265 years. A study

of 57,302 patients with ground-level falls demonstrated higher rates of intracranial injury and
in-hospital mortality among adults aged 270 years.

On the basis of its review, the Panel elected to strengthen the criterion regarding older adults
in Step Four. “SBP <110 might represent shock after age 65” and “low-impact mechanisms
(e.g., ground-level fails) might result in severe injury” were added under “Older Adults” in
Step Four because under triage of the older adult population is a substantial problem, the
evidence reviewed suggests that the physiologic parameters used in younger patients might
not apply to older adults, occult injury is likely to be greater among older adults, low-energy
transfers (e.g., ground-level falls) might result in serious injuries in this population, and field
identification of serious injury among older adults must be more proactive.

National Perspective

At the 8th Annual London Trauma Conference last December Professor EEE the
National Clinical Director for Trauma spoke on the Elderly in Trauma Epidemic, with the 75+
population set to double by 2027, Prof. Moran discussed how we need better triaging, more
appropriate transfers (not sending all to major trauma centres), network guidelines, and
trauma-geriatricians if we are to deal with this ‘demographic tidal wave’.

Elderly Trauma Working Group

In response to this WMASFT has liaised with the regional trauma network office and

Professo EEE '¢ clinical lead for the regional trauma system to set up an elderly
trauma working group to identify the issues facing pre hospital providers with elderly trauma
patients and provide advice and recommendations

Elderly Trauma Working Group
Friday 3° July

1. Welcome and introduction

2. The Facts ~ Professor Porter

3. Pre-hospital Triage

4. ED Triage

5. Earlier inpatient Recognition

6. AOB