Prevention of Future Deaths reports · 2015
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 report | 10 Jul 2015 |
|---|---|
| Reference | 2015-0267 |
| Deceased | Colin Moulton |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| Category | Community health care and emergency services 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: 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
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.
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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