Prevention of Future Deaths reports · 2015

Colin Moulton

Regulation 28 report to prevent future deaths, reference 2015-0267, written 10 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Jul 2015
Reference2015-0267
DeceasedColin Moulton
CoronerSimon Nelson
Coroner areaManchester North
CategoryCommunity health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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. The Department of Health

2. Messrs. Weightmans

3. North West Ambulance Service

4. Family of the deceased

CORONER

am Simon Nelson, Senior Coroner for the Coroner area of Manchester North

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013

INVESTIGATION and INQUEST

On the 20° February 2013 | commenced an investigation into the death of Colin Moulton for whom the
cause of death was confirmed at Inquest at being that of 1a) Bronchopneumonia with Hypothermia;
Alcoholic Liver Disease and Ischaemic Heart Disease, whilst not causative of death, all being contributory
factors.

At an Inquest hearing on the 25" June 2015, the Inquest was concluded with the following narrative —

‘Colin Moulton was discovered deceased within 25 feet of the perimeter wall of the Irwell Unit
within the grounds of Fairfield General Hospital Bury shortly after 9am on the 14" February 2013.
He had been admitted to the Accident and Emergency Department of Fairfield General shortly
before 16:00hrs on the 13" February. Whilst en-route to the Accident and Emergency Department
on the 13" February, paramedics observed that Mr Moulton was clearly unwell, suffering from
abdominal pains and tachycardia and was becoming increasingly confused. By reason of
ineffective communication between paramedic and nursing staff, Mr Moulton was incorrectly
triaged and accorded a lower priority than was appropriate. Crucially, Mr Moulton’s confusion
went unrecognised with the result that when he attempted to leave the department, there was no
formal capacity assessment; no discussions to involve a clinician; no consideration of the
involvement of a member of the security staff and no formal documentation completed- all of
which amounted to sub-optimal nursing care. The evidence does not show whether Mr Moulton
would have remained within the department had the correct procedures been followed but more
likely than not, the provisions of the Trust’s missing person policy would have been invoked. By
reason of the missed opportunities to render effective care, Mr Moulton’s death was contributed to
by neglect.

CIRCUMSTANCES OF DEATH

As above

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. When Mr Moulton was admitted to A & E on the 13" February 2013, critical information was
conveyed by means of a verbal handover from the paramedic to the receiving triage nurse.
Following this incident, The Pennine Acute Trust now requires the receiving triage nurse to have
access to and have sight of the paramedic pro-forma with the additional requirement that those
actions be documented. [t would be helpful if an additional copy of the paramedic pro-forma
could be given to and remain with the receiving triage nurse.

2. At approximately 5pm on the 13” February 2013, a number of administrative staff, whilst en-route
home saw Colin Moulton within the hospital grounds near to the Irwell Unit. They perceived him to
be ‘in difficulty’. One of the staff members called for the assistance of an ambulance which duly
attended and the paramedics on board apparently were unable to locate Mr Moulton. Had the
Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, this may
have tied in with earlier concerns in relation to Mr Moulton of which the Hospital Trust was aware.
The Ambulance Trust is requested to consider whether in the future, third parties such as Hospital
Trusts might be notified in such circumstances.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and ! believe each of you respectively 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 4"
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.

COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
The Department of Health

Messrs. Weightmans

North West Ambulance Service

PY N bP

Family 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 ina complete or redacted or summary from. He may send a
copy of this report to any person who he believes may find it usefulor 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: 10" July 2015

Responses

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.

Response from Department of Health (PDF)
From Ben Gummer MP
Parliamentary Under Secretary of State for Care Quality

Department Richmond House
of Health oMondon
POCS 949547 emia ens
Tel: 020 7210 4850
Mr. S. Nelson
Senior Coroner
The Phoenix Centre 26 AUG 2015
Church Street
Heywood
OL10 ILR

Lacs W Nelo.

Thank you for your letter of 10" July 2015 following the inquest into the death of Mr
Moulton. I was very sorry to hear of Mr Moulton’s death and wish to extend my
sincere condolences to his family.

You have two main concerns in this case — the first focusses on the ineffective
communication between paramedic and nursing staff during the handover of Mr
Moulton to A&E at Fairfield General Hospital (FGH). You state that this resulted in
Mr Moulton being incorrectly triaged by the nursing staff and not receiving the most
effective care.

The second concern is over the lack of communication between the North West
Ambulance Service (NWAS) and the Hospital Trust, when NWAS paramedics were
called to provide assistance to Mr Moulton after he had been seen in difficulty in the
grounds of the Hospital.

I consider that both of your concerns are for local comment and resolution and I note
that you have sent a copy of your report to the NWAS. I am aware that NWAS has
already responded, addressing the issues you raise and asking that you redirect your
specific concerns to FGH for its consideration also.

Further to this however, I am able to provide some relevant comment and guidance
from a national perspective, which I hope you will find of use.

Regarding your first concern, you point out that the Trust has now implemented
improved handover procedures between paramedics and A&E staff which should
ensure that the triage nurse sees any patient notes made by the paramedics and
documents this action. However, you suggest that this could be further improved if the
triage staff could, not only see but retain a copy of the paramedic notes.

NWAS has advised that its staff always leave a patient report form (PRF) at every
hospital following a patient transfer. A copy of this form also remains with the patient
following admission.

FGH has very specific patient handover procedures which require NWAS to leave a
copy of the PRF with the hospital receptionist for placing with hospital documentation
which is subsequently passed to the triage nurse once the patient has been booked in.
A verbal handover of the patient is also provided to the triage nurse. Such robust
procedures should ensure that FGH triage staff have access to important patient
information whenever required.

As the above has demonstrated, the actual detail of patient handover processes and
procedures are a matter for each local Trust to decide. However, I can assure you that
the Department of Health does expect all ambulance trusts to have effective clinical
handover procedures in place with local acute trusts. This includes conveying
information such as the patient’s vital signs, history, injuries, name and age and
documenting this action.

In addition, the Royal College of Physicians, on behalf of NHS England and the
Health and Social Care Information Centre, has prepared, “Professional guidance on
the structure and content of ambulance records”.

Such records should include relevant clinical risk factors, presenting complaints or
issues and safety alerts. All ambulance trusts are currently working to embed these
standards into operational practice.

A copy of the guidance can be accessed from:

http://www.england.nhs.uk/wp-content/uploads/2014/12/ambInce-rec-guid.pdf

In addition, NHS England’s review of urgent and emergency care proposes a
fundamental shift in the way urgent and emergency care services are provided. Their
vision is to deliver more emergency care closer to home, in centres with the very best
facilities and expertise, thereby helping to avoid unnecessary journeys to, or stays in,
hospital.

For this vision to be successful there needs to be effective, timely and appropriate
transfer of key patient information that follows the patient through the healthcare
system. NHS England is working with partners to develop an enhanced summary care
record to enable greater access to patient care plans, including end of life care records,
special patient notes and mental health crisis notes.

I note that this case also raises issues about the standard of nursing care, which, in this
instance, you consider amounted to neglect. Whilst I cannot comment personally on a
matter which is for the local Trust to address, I can confirm that all nurses must
register with the Nursing and Midwifery Council (NMC) and meet set professional
standards so they are fit for practise in the UK.

All registered nurses are expected to be familiar with and to uphold the standards in
the NMC’s publication: The Code: Professional standards of practice and behaviour
for nurses and midwives. If an allegation is made about a nurse who may not meet the
professional standards required in the UK, as set out in The Code, the NMC has a duty
to investigate and, where necessary, take action to safeguard the health and well-being
of the public. In serious cases this action can include removing the nurse from the
NMC’s register thereby preventing them from practising in the UK.

I am grateful to you for bringing the circumstances of Mr Moulton’s death to my
attention and hope that yom find this reply helpful.

en, |

BEN GUMMER

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