Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0221, written 12 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jun 2015 |
|---|---|
| Reference | 2015-0221 |
| Deceased | Nancy Hughes |
| Coroner | John Gittins |
| Coroner area | North Wales (East & Central) |
| Category | Hospital Death (Clinical Procedures and medical management) 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: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW 1 | CORONER lam JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East and Central)] 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 the 6th of January 2014 | commenced an investigation into the death of Nancy Hughes (DOB 26.06.30, DOD 03.01.14). The investigation concluded at the end of the inquest on the 11" of June 2015 and | recorded a conclusion of an accidental death. The cause of her death being due to 1(a) Bronchopneumonia and Congestive Cardiac Failure (b) Fractured Neck of Femur (Operated) and Arterial Atheroma (c) Fall 2. Alzheimer's Disease 4 | CIRCUMSTANCES OF THE DEATH The Circumstances of the death are that the Deceased was a lady with Alzheimer’s Disease and had been a patient on the Tawel Fan Ward at Ysbyty Glan Clwyd in June 2013 and had been placed on Risperidone before her discharge to a local care home at the beginning of July 2013. There was no review of this medication undertaken contrary to accepted medical practice and she fell at the care home on the 16" of December 2013 fracturing her hip. She underwent an operation to repair the fracture the following day but then had a further unwitnessed fall in hospital on the 28! of December whilst sitting out. She declined thereafter and passed away on the 3% of January 2014. 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. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken. 2. That the evidence given oy Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisations 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 7'* August 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Person | (Son of the Deceased) lam 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] 12% June 2015 [SIGNED BY CORONER]
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.
Bwrdd lechyd Prifysgol Ysbyty Gwynedd, Penrhosgarnedd, Bangor, a) Betsi Cadwaladr Gwynedd, LL57 2PW 4 University Health Board een eene eee eeeceenee WALES Ein cyf/Ourref: INC63731 PRIVATE & CONFIDENTIAL Eich cyf/ Your ref: Rhif Ysbyty / Hospital Number: Mr John Gittins . . H.M. Coroner North Wales Rhif GIG / NHS Number: (East and Central) ‘@: 01248 384194 County Hall Gofynnwch am / Ask for: 5a a atay Road Ffacs / Fax: 01248 385318 Denbighshire E-bost / Email: concernsteam.bcu@wales.nhs.uk LL15 1YN Dyddiad / Date: 24 August 2015 Dear Mr Gittins Re: Inquest of Nancy Hughes — Regulation 28 of the Coroners Regulations 2013 Following the conclusion of the above inquest and receipt of the Regulation 28 of the Coroners (Investigations) Regulations 2013 Report, you expressed two concerns and instructed the Health Board to take action to prevent further deaths. | will address each in turn detailing the following actions: 1. There was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken. This is a requirement under the Mental Health (Wales) Measure; there is a requirement for patients to have a named individual who coordinates their care, ie their Care Coordinator. For patients known to community teams their care coordinator will be a member of staff from that team, this could be a Consultant, a nurse, a social work or other professional. For patients not previously known to community teams prior to their admission, a named nurse (care coordinator) must be allocated to that patient within the first 24 hours of the admission ~ this is part of the patient’s 7 day admission pathway. The care coordinator, or named nurse have a responsibility for maintaining contact with the patient and the care team looking after the patient, if they are transferred for medical treatment into an acute hospital setting. This would include review of medication. BCUHB Mental Health Medicines Management Group has developed a Prescribing Guideline for the Management of Behavioural and Psychological Symptoms of Dementia. The guideline states: “Monitoring - Following prescribing the patient should be reviewed at least weekly for in- patients and 3 monthly in primary care. Where the antipsychotic was started by the consultant and the GP is asked to provide ongoing review this must be clearly documented in the letter to the GP giving clear guidance on when and how to reduce the medication. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbe.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk Review and Discontinuation - At 6 or 12 weeks: The review should be directed towards the target symptom for which the medication was prescribed. If target symptoms have improved and the behaviour is settled, the medication should be gradually reduced e.g. by reducing the dose by 50% or the smallest increment possible every 2 to 4 weeks until the medication has been stopped. If symptoms return then continue using the lowest beneficial dose. Where no improvement is noted, consider slowly decreasing the dose and consider an alternative antipsychotic or seek specialist advice. Continue to review regularly while remaining on treatment.” Guideline is embedded for information. BCUHB Unlicensed Antipsychotics in Den 2. That the evidence given by pF Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support. The role of the Care coordinator or named nurse incorporates key responsibilities for ensuring effective communication between the transferring ward and receiving ward. When patients are transferred from mental health facilities to an acute secondary care setting, mental health medical records should follow the patient. The Mental Health Improvement Group is also working to improve this. | hope these actions are sufficient to reassure you, but trust should you require further information you will not hesitate to contact me further. Yours sincerely nes Director of Corporate Services on behalf of the Chief Executive C.C. Senior Investigation Manager Interim Head of Nursing, Mental Health Consultant Psychiatrics, Head of Acute Care
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