Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0225, written 13 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Mar 2015 |
|---|---|
| Reference | 2015-0225 |
| Deceased | Philip Robinson |
| Coroner | Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. The Chief Executive of the Doncaster and Bassetlaw Hospitals NHS Foundation Trust 1 CORONER I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 2 CORONER’S LEGAL POWERS I 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 4th April 2014, I commenced an investigation into the death of Philip Robinson, age 42 years. The investigation concluded at the end of the inquest on 28th January 2015. The conclusion of the inquest was a Narrative: Philip Robinson died on the 26th March 2014 at Bassetlaw Hospital from an acute Myocardial Infarction. He had severe coronary artery disease. He had been discharged the previous day, with the significance of his clinical condition not appreciated by the treating team. 4 CIRCUMSTANCES OF THE DEATH Mr Robinson was a reasonably fit man, although he did have risk factors for the development of early Coronary Artery disease. He developed symptoms of vomiting and breathlessness over the three days prior to his death, with coughing up blood and pain in his lower back and side. Two days prior to his death he was seen at the Emergency Department at Bassetlaw Hospital. He was sent home, but asked to return that afternoon as some investigations were abnormal. He was monitored overnight on the Assessment and Treatment unit, and had an episode of breathlessness during the night. On the morning of the 25th March, the day before his death, he was seen by a Consultant, and a scan organised, to look for a pulmonary embolus. Throughout the day Mr Robinsons National Early Warning Scores rose from 1 to 3. There was no escalation for medical review. He was discharged home again, and readmitted the following day in cardiac arrest from which he could not be resuscitated. The Trust completed a Serious Untoward Incident report, produced an action plan, and submitted further statements and reports following the Inquest. All these documents went some way to addressing concerns raised in evidence, 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. 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. – The results from audits of compliance with safe discharge arrangements using a discharge stamp, including the recording of the Early Warning Score on discharge are unsatisfactory 1 The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’ The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 12th May 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (Widow, and Next of Kin) I 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. 9 13th March 2015 Dr E A Didcock 2
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.
Doncaster and Bassetlaw Hospitals NH5 Foundation Trust Medical Director’s Office Our Ref RIC/jj 11 May 2015 Dr E Didcock HM Assistant Coroner for Nottinghamshire The Council House Old Market Square Nottingham NG1 2DT Dear Dr Didcock Re Mr Philip Robinson - D.O.B. - 5.3.1972 : D.O.D. - 26.03.2014 | am responding to the Regulation 28 Report dated 16 March 2015 sent to Mr Pinkerton, Chief Executive of Doncaster and Bassetlaw Hospitals NHS Foundation Trust. | have been assisted in my response by i ——/ Acute Physician & Assistant Care Group Director, Matron at Bassetlaw Hospital and PY Patient Safety Facilitator, Emergency Care Group. | will respond to the issues raised as follows: ¢ The results from audits of compliance with safe discharge arrangements using a discharge stamp, including the recording of the EWS on discharge are unsatisfactory. The discharge stamp was trialled and found to be unsuccessful within ATC with its high turnover of patients. Since this incident ATC has undergone an “observations project” which included the documentation and recognition of EWS on discharge. The i-Hospital white board system is due for implementation later this year. This will highlight which patients have a high EWS and the next due time of observations. On discharging a patient from the system, the system will provide the nurse with an additional opportunity to assess EWS on discharge. The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital The safety brief at the end of the ward round involves the whole of the ward team including HCA’s to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit. Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC. The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson's admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated There are no clear national guidelines to assist medical staff when ordering ECGs in patients who present with breathlessness. Acute medicine at Bassetlaw relies on early senior review by consultants. However variation in clinical judgement will occur. This incident has been communicated widely within the emergency care group by way of awareness. The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’ This is now no longer seen as an acceptable option to leave a SHO without registrar cover out of hours. In 2015 to date there has been three occasions where no cover could be obtained. On these occasions the consultant on-call was informed and provided extra support to the SHO. The issue around senior medical staffing remains a concern within the Trust. We currently have an ongoing recruitment programme and are considering alternative ways to utilise senior staff within the trust to support this. The hospital 24/7 program is aimed at providing senior nurse practitioner cover to support the hospital out of hours. Similar hospital sites have implemented this system with good outcomes with regards patient safety. The i-Hospital is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded. The “status at a glance” board is now embedded in practice on ATC. The board shows the EWS Score and the next time observations are due to be performed. The i-Hospital program is progressing well and plans remain optimistic that it will be in place by late summer 2015. | trust that the above wiil allay your concerns. Please do be hesitate to revert back to me should you feel it necessary. j i . Yours sincerely a MD. ChM. M.Ed FRCS Deputy Medical Director - Clinical Standards Cc | Head of Risk and Legal Services Mike Pinkerton, Chief Executive, DBHFT HE Medical Director, DBHET i i i i f i \
See every Prevention of Future Deaths report matching Doncaster and Bassetlaw Teaching Hospitals 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.