Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0373, written 14 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2015 |
|---|---|
| Reference | 2015-0373 |
| Deceased | Alan Tear |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Mr John Adier University Hospitals of Leicester NHS Trust Belgrave House Leicester General Hospital Gwendolen Road Leicester LES 4PW CORONER | am Lydia Brown, assistant coroner, for the coroner area of Leicester City and Leicestershire South 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 6 October 2015 | commenced an investigation into the death of Alan Tear. | returned the following narrative conclusion: Alan Tear died on the 1st May 2015, in Leicester General Hospital from post-procedure complications following the insertion of a biliary drain. At the time he was not being observed on the ward in accordance with his needs and opportunities to recognise and intervene were lost. It cannot be said whether any earlier intervention would on the balance of probabilities have altered the outcome. Cause of death 1a Intraperitoneal haemorrhage 1b Biliary drain insertion for obstructive jaundice 1c Cholangiocarcinoma 2. Ischaemic heart disease, hypertension, diabetes mellitus '4 | CIRCUMSTANCES OF THE DEATH Mr Tear was receiving palliative treatment for cholangiocarcinoma. He underwent a drain insertion on 30" April 2015 by the interventional radiology team and appeared to cope well with this. It was recognised pre-operatively that there was a high risk of procedural complications and a 10% risk of mortality. He had appropriate observations in recovery and was then returned to the ward with post-operative instructions for regular observations. Most of these observations were not carried out. One set of observations that should have raised concerns did not result in any action. Mr Tear died 11 hours post-operatively from a bleed caused by the drain that had become misplaced and caused a perforation of the peritoneum. 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. Post-operative instructions were not followed by the nursing staff. 2. Post-operative observations were not reported to medical staff as required when the EWS was rising. 3. It was not clear that the Intervention Radiology team knew or understood what observations the nursing staff would carry out and the communication between the teams needs to be reconsidered. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 Wednesday 9” December 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 BE cause: of the deceased are Quality Commission. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina plete or redacted or summary form. He may send a copy of this report to érson who he believes may find it useful or of interest. You may make represey is to me, the coroner, at the time of your response, about the release or th ication of your response by the Chief Coroner. [DATE] 14" October 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.
University Hospitals of Leicester ,..1:bj NHS Trust HM Coroner for Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG yth December 2015 Dear Mrs Mason Re: Alan Henry Tear Thank you for the Regulation 28 Report sent by your Assistant Coroner on 14th October 2015 I am now in a position to respond . As indicated Mr Tear died from post-procedure complications on the 1st May 2015 following the insertion of a biliary drain by the interventional radiology team and transfer to a surgical base ward . The Regulation 28 Report raises three matters of concern:- 1. Post-Operative instructions were not followed by nursing staff. 2. Post-operative observations were not reported to medical staff as required when the EWS was rising. 3. It was not clear that the lnterventional Radiology team knew or understood what observations the nursing staff would carry out and the communication between the teams needs to be reconsidered. At the point of transfer of Mr Tear from the interventional radiology team to the surgical ward there should have been an effective handover between nursing staff which should have been implemented on the surgical ward . This did not happen in this occasion. Handover is effected orally and supported by a sheet documenting the required frequency of nursing observations for the patient. This sheet follows the patient and documents the care needed. Regrettably the frequency of nursing observations was not undertaken in accordance with the patient's requirements as documented on the handover sheet. As an immediate action after the inquest the matron met with all nursing staff on the ward to discuss what had occurred in this case. In particular ward staff Uni versity Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal lnfinnary Website: www.leicestershospitals. nhs.uk were required to consider and be aware of the required frequency of observations as set out in the handover sheet. Additionally, as part of our wider learning, our Clinical Director for the Clinical Management Group (CMG) will, along with the Medical Lead for Imaging ensure that there is a continuous teaching session for CMG staff on the issue of lnterventional Radiology for Surgical patients ; describing the techniques, for each different procedure, complications, identification of complications and escalation . This will have occurred before the end of December 2015. frequency of observation Furthermore our Head of Nursing for the CMG will ensure that there is an audit undertaken to monitor the compliance with nursing instructions following radiology procedures. This audit will have been completed by the end of November 2015 and repeated thereafter according to its findings. The findings will be reported to the CMG Board . to introduce a system With a view to strengthening our systems and processes generally the Trust intends recording nursing observations. This system (E-obs) is expected to be in place by the end of March 2016 and is led jointly by our Interim Deputy Medical Director and Assistant Chief Nurse. Once implemented, this system will issue alerts when required highlighting when observations have not been undertaken. for electronically As a result of this inquest we will be redesigning the sheet which documents the required frequency of observations to be undertaken on the receiving ward. The sheet and required frequency will vary according to the type of the procedure performed. To optimise the hand over the sheet will be signed by the lnterventional radiology nurse and receiving ward at the radiology theatre. Our Medical Lead for Imaging, in consultation with surgical colleagues, will have completed this work by the end of December 2015. It is said that the post-operative observations were not reported to med ical staff when EWS was rising. I understand that this was because you heard evidence that where there were conflicting EWS scores taken within a very short period it is always appropriate to act as if the more worrying score is the more accurate score. As you will be aware EWS is a tool to assist clinicians to identify deteriorating patients. It relies on various parameters (including blood pressure) being measured and scored. However it does not replace clinical judgement and its usefulness depends on the reliability of the scores identified. Where there is genuine and immediate doubt as to the reliability of any particular reading our practice is to repeat that reading and place reliance on the score which is considered to be valid . We do not consider that it would sensible to change this practice and will not be doing so. In this case, for a particular EWS score, there were two measu rements of blood pressure, one undertaken on the patient's arm with another University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www. leicestershosp itals.nhs. uk In some measurement taken very shortly thereafter on the patient's leg. cases a patient's habitus can cause the blood pressure arm-cuff to be ill-fitting which can render a result unreliable. This would explain the need for the observation to be repeated on the patient's leg. However we remain committed to improving our on-going education at the Trust on the EWS scoring tool. Our Interim Deputy Medical Director and Assistant Chief Nurse are currently rewriting the EWS training package and will use what occurred in this case to ensure that clinical staff are given clarity on the actions that they must take when there is either doubt as to the reliability of any particular EWS score or the EWS score is considered to require escalation. This work is due to be completed by the end of March 2016. I trust that this provides you with the assurance that you seek that we take these matters seriously. If you wish for any further information please feel free to write to me again. Yours sincerely Chief Executive Cc: , Assistant Director (Head of Legal Services) , Interim Medical Director , Chief Nurse Uni versity Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www. leicestershospitals.nhs.uk
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