Prevention of Future Deaths reports · 2015

Alan Tear

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 report14 Oct 2015
Reference2015-0373
DeceasedAlan Tear
CoronerLydia Brown
Coroner areaLeicester City and South Leicestershire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedUniversity Hospitals of Leicester NHS Trust
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

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]

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 University Hospitals of Leicester NHS Trust (PDF)
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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