Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0240, written 24 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 | 24 Jun 2015 |
|---|---|
| Reference | 2015-0240 |
| Deceased | Anthony Geerts |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| 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.
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 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: i 1, Matthew Kershaw Chief Executive, Brighton & Sussex University Hospital NHS Trust 2. — Head of Safety Brighton & Sussex University Hospital NHS Trust 3. — Medico Legal Services Manager, Brighton & Sussex University Hospital NHS Trust 4. Nurse in Charge of Twineham Ward, Princess Royal Hospital, Lewes Road, Haywards | Heath, RH16 4EX 4 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 1*' December 2014 | commenced an investigation into the death of MR. ANTHONY GEERTS The investigation concluded at the end of the inquest on 10" June 2015.The conclusion of the inquest was that - Tony GEERTS died of pneumonia following an accidentally fractured left neck of femur in circumstances to which neglect at Princess Royal Hospital contributed. 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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, — Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6". His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. | was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to Highgrove Nursing Home as soon as possible after the 6”, Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6”. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10". Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11" he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived ina poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16"" with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21°. Specifically at Princess Royal Hospital: e Notes not completed. * Nonursing notes and no NEWS for 10" or 11" ¢ Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. * No plan for physiotherapy * No rehabilitation on Rehabilitation Ward from 6" -10". Exercise on the 10" not properly documented. * No proper notes or Rationale for transfer to Bailey Ward on 10"/11". Transfer procedure not followed. Transfer not documented. No referral of lack of urinary continence. Therefore no plan regarding this. Failed Trial without catheter on 3° November 2014. Bowel monitoring chart not complete Discharge planning non-existent or inadequate -Communication with patient and family virtually non-existent No senior review from 4" November 2014; possibility of chest infection not followed up. Should have had a blood test as requested on 11'" November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. * Discharge lounge information incorrect. 6 ACTION SHOULD BE TAKEN 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 30B Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 In my opinion action should be taken to prevent future deaths and | believe you AND your organisation 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 10" September 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. 8 COPIES and PUBLICATION 1 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Pp [| — Chair of Brighton & Sussex University Hospitals Secretary of State for Health, Department of Health H — Chief Executive NHS England National Patient Safety Agency - ~ Director of Public Health . Ee Director of Clinical Quality Who may find it useful or of interest. J am also under a duty to send the Chief Coroner a copy of your response. DONAAPwWN 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 Date: 24th June 2015. SIGNED BY: Veronica HAMIL’ Senior Coroner Brighton and Hove
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 ref: VHD/LP/INQ 29/15 (214/14) Our Ref: MK/MLS/C9/14/127 University Hospitals NHS Trust Headquarters 10 September 2015 The Royal Sussex County Hospital Eastern Road Brighton BN2 5BE Miss V Hamilton-Deeley ° HM Senior Coroner Tel: 01273 664902 Coroner's Office, Woodvale Lewes Road BRIGHTON BN2 3QB Dear Miss Hamilton-Deeley The Late Anthony Geerts, date of birth: 01 April 1922 NHS No: 420 208 7437 Thank you for your letter of 24 June 2015, and for drawing your concerns to our attention. We are always willing to review our practices in this Trust, in order to identify improvements which can be made in the light of experience. May we start by expressing our sympathy on their sad loss to the family of Mr Geerts. Since he died, considerable changes have been implemented within this Trust specifically relating to the management of patients who have suffered a fractured neck of femur. Instead of routinely operating at the Royal Sussex County Hospital and then transferring the patients to the Princess Royal Hospital for rehabilitation, the whole service is now provided at the Princess Royal Hospital. This provides greater continuity for the patients, and indeed for the staff, and eliminates an opportunity for confusion or breakdown in communication between staff working in different places. Such continuity would clearly have been preferable for Mr Geerts, especially bearing in mind his history of anxiety, and it is particularly regrettable that it was necessary to transfer him from one site to another during his admission. The integration of the neck of femur service has been accompanied by detailed review and revision of the provision on the ward and more widely, for the benefit of this group of patients. Changes implemented on Twineham ward have included: a) the recruitment of a new Clinical Nurse Practice Educator based on Twineham ward. This postholder is able to assist staff with a range of issues, including providing training on all aspects of communication (written and verbal) b) introduction of integrated documentation for use by all the clinical staff treating each patient on the ward c) joint development of a training package for all the staff based on Twineham ward, by the senior physiotherapy and nursing staff, to assist with accurate and detailed documentation. This includes a specific focus on the potential consequences of poor documentation d) increased physiotherapy staffing (both trained and therapy support staff), reducing the occasions when it is not possible for a patient to have physiotherapy as planned, with recognition that any patient that is not seen on one day must become one of the highest priorities for the next day e) closer liaison between nurses and physiotherapists, about relevant continuity of care by nurses for patients at times when physio- therapists are not present f) provision of a senior physiotherapy lead member of staff based on Twineham ward g) educational sessions with ward nurses to explore the rationale for moving patients. This will include both emphasis on the need to provide adequate information to the clinical site manager if consideration is being given to moving a patient (especially late at night), and teaching on the documentation requirements (including completion of the transfer document), should it be unavoidable for a patient to be moved from one ward to another. This will help to ensure that adequate information accompanies any patient who, for whatever reason, has to be moved from one ward to another h) review of senior medical input on Twineham ward. The Clinical Director for the musculoskeletal service has emphasized that every patient on Twineham ward should normally be seen by a consultant orthopaedic surgeon or orthogeriatrician at least four times a week (including one day at the weekend), including a conversation with the patient and review of their progress with them. Any patient who is sick should be seen daily by a consultant. The junior medical staff have been reminded that they must attend with the consultant, and should record every such discussion in the notes, if the consultant does not do this themselves In addition, there have been discussions with the clinical site managers, who are the senior nurses on duty 24 hours a day on each site, with responsibility for allocating beds for patients. These staff are well aware that it is undesirable to move any patient late at night, even though this may be unavoidable in order to accommodate patients admitted through the Emergency Department. = Scnool oa We will be reviewing the progress of these changes in services for people with fractured necks of femur at the Princess Royal Hospital, and any further learning will be used to refine and develop the new service further. Thank you once again for raising your concerns with us. Yours sincerely Matthew Kershaw [i h care Ss cepreccraae Chief Executive Chief of Safety Medicolega ard Manager, Services Manager Twineham Ward “approved electronically ical school
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