Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0384, written 22 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Sep 2015 |
|---|---|
| Reference | 2015-0384 |
| Deceased | William Harnell |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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.
ANDREW JAMES COX Assistant Coroner for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Medical Director Plymouth Hospitals NHS Trust Derriford Road Plymouth PL6 8DH 1 CORONER lam ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 15/12/2014 | commenced an investigation into the death of William John Charles Harnell then aged 67. The investigation concluded at the end of the inquest on 15 September 2015. The conclusion of the inquest was that Mr Harnell died as the result of an accident. He had suffered a fractured left neck of femur while attempting to mobilise from his wheelchair in the early hours of 22 October 2014. The cause of death was given as: 1 (a) Hospital Acquired Pneumonia; 1 (b) Left Hip Fracture; a] Cerebral Vascular Event and left sided weakness. 4 CIRCUMSTANCES OF THE DEATH Mr Harnell was seen in the emergency department at 04.47 hours on 22 October 2014. An X- ray of his left hip was performed at 05.34 hours. This was interpreted as being “not conclusive so it needs either repeat film with better analgesia/MRI to exclude fracture”. Mr Harnell was admitted to the Medical Assessment Unit and from there on to Honeyford Ward where he came under the care of The X-ray was not formally reported until 27 October 2014 (5 days after admission). The report noted that “the left hip is markedly rotated making interpretation difficult. There is no evidence of a fracture. If there is ongoing clinical concern then a repeat X-ray is recommended”. Mr Harnell was re-examined on 28 October when he was found to have a good range of pain free movement. On 29 October, however, the physiotherapy team noted that he was complaining of left hip pain and a repeat X-ray of the hip was requested. This did not take place until 2 November and was not reported until 3 November when an impacted fracture of the left neck of femur was demonstrated. On 3 November it was decided that Mr Harnell should have non-operative management of his fractured hip with pain relief and mobilisation as tolerated. While he was fit for discharge from 4 or 5 November, Mr Harnell remained in Hospital until he developed Pneumonia and died on 15 December 2014. It was not clear from the evidence | heard that the initial delay in reporting the first X-ray and the subsequent delay in organising an the reporting of the second X-ray caused Mr Harnell’s death 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297 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) There was a delay of 5 days in the formal reporting of the original X-ray; (2) There was a further delay of 2 to 3 days in the obtaining of a second X-ray; (3) The Consultant responsible for Mr Harnell’s care did not know of Hospital guidance that an MRI should be obtained where a first X-ray is inconclusive and/or the patient complains of pain or fails to mobilise. It was felt that this may be due to the fact that Mr Harnell ended up on a Respiratory Ward (even though he had a fracture of his hip) and what may have been known to Orthopaedic Clinicians was not known to Respiratory Physicians. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you P| have the power to take such action. | heard evidence at Inquest from that the Trust had made efforts to reduce the lengthy delays in X-ray reporting. | was told that the situation had been improved but that there continued to be delays. | was further told that this is a national problem (and not peculiar to Derriford) and consequently, | have also written a Regulation 28 Report to the Department of Health. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 November 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: a | have also sent it to The Department of Health who may find it useful or of Interest. | am also under a duty to send the Chief Coroner a copy of your response. 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. Dated 22 September 20 jouth Torbay and South Devon 3 The Crescent, Plymouth, PL! 3AB Tel 01752 204 636 | Fax 01752 313297 ANDREW JAMES COX Assistant Coroner for Plymouth Torbay and South Devon | 2 CORONER’S LEGAL POWERS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr J Hunt MP Secretary Of State For Health Richmond House 79 Whitehall London SW1A 2NS CORONER |am ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 15/12/2014 | commenced an investigation into the death of William John Charles Harnell then aged 67. The investigation concluded at the end of the inquest on 15 September 2015. The conclusion of the inquest was that Mr Harnell died as the result of an accident. He had suffered a fractured left neck of femur while attempting to mobilise from his wheelchair in the early hours of 22 October 2014. The cause of death was given as: 1 (a) Hospital Acquired Pneumonia; 1 (b) Left Hip Fracture; tl Cerebral Vascular Event and left sided weakness. CIRCUMSTANCES OF THE DEATH Mr Harnell was seen in the emergency department at 04.47 hours on 22 October 2014. An X- ray of his left hip was performed at 05.34 hours. This was interpreted as being “not conclusive so it needs either repeat film with better analgesia/MRI to exclude fracture”. Mr Harnell was admitted to the Medi ssment Unit and from there on to Honeyford Ward where he came under the care o' The X-ray was not formally reported until 27 October 2014 (5 days after admission). The report noted that “the left hip is markedly rotated making interpretation difficult. There is no evidence of a fracture. If there is ongoing clinical concern then a repeat X-ray is recommended”. Mr Harnell was re-examined on 28 October when he was found to have a good range of pain free movement. On 29 October, however, the physiotherapy team noted that he was complaining of left hip pain and a repeat X-ray of the hip was requested. This did not take place unti! 2 November and was not reported until 3 November when an impacted fracture of the left neck of femur was demonstrated. On 3 November it was decided that Mr Harnell should have non-operative management of his fractured hip with pain relief and mobilisation as tolerated. While he was fit for discharge from 4 or 5 November, Mr Harnell remained in Hospital until he developed Pneumonia and died on 15 December 2014. It was not clear from the evidence | heard that the initial delay in reporting the first X-ray and the subsequent delay in organising anXthe reporting of the second X-ray caused Mr Harnell's death | 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297 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) | heard evidence during the course of the Inquest that delays in the reporting of X-rays are not peculiar to Plymouth Hospitals NHS Trust but are a National problem. | was further told that this is as a consequence of a lack of qualified Radiologists to complete the reports. (2) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Mr J Hunt MP have the power to take such action. It is plainly undesirable for a patient not to have a conclusive diagnosis from X-ray of a fractured hip for 10 days following admission into Hospital. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 November 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: | have also sent it tol Medical Director, Plymouth Hospitals NHS Trust who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. 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. Signature__\_, Assistant Corénet for P) ymouth Torbay and South Devon 3 The Crescent, Plymouth, PLI 3AB Tel 01752 204 636 | Fax 01752 313297 ANDREW JAMES COX Assistant Coroner for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: nn Director Of Social Services County Hall Truro Cornwall CORONER lam ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon 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. http://www. legislation.gov.uk/ukpqa/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 15/12/2014 | commenced an investigation into the death of William John Charles Harnell then aged 67. The investigation concluded at the end of the inquest on 15 September 2015. The conclusion of the inquest was that Mr Harnell died as the result of an accident. He had suffered a fractured left neck of femur while attempting to mobilise from his wheelchair in the early hours of 22 October 2014. The cause of death was given as: 1 (a) Hospital Acquired Pneumonia; 1 (b) Left Hip Fracture; " Cerebral Vascular Event and left sided weakness. CIRCUMSTANCES OF THE DEATH Mr Harnell was admitted to Hospital on 22 October. The fracture of his hip was not diagnosed until 3 November. | have already written to Plymouth Hospitals NHS Trust to raise concerns in this regard. At Inquest | was told that Mr Harnell was fit to be considered for discharge from approximately 4 November 2014. Subsequently, he had chest pain which required investigation and may have delayed matters by approximately a week. By the middle of November, however, Mr Harnell was ready for discharge. Regrettably, Mr Harnell was not discharged and remained in Hospital until he developed Pneumonia and died on 15 December 2014 approximately one month later. | heard evidence at Inquest that part of the reason why Mr Harnell continued to remain in Hospital was that he presented as an extremely challenging patient. He was, on occasions verbally and physically abusive to staff. It was not immediately clear whether this was due to a mental health condition or a personality defect. | heard evidence that, but for this behaviour, Mr Harnell would have been discharged to a Community Hospital. That option was not available, however, and neither was a return to his home address given the decision to treat the hip fracture conservatively, It seems clear from the evidence that by the middle of November it was plain Mr Harnell could only be discharged, ing Home of some sort. It was not, however, until 28 November when | understond the Social Worker involved rang five homes that may be able to offer this sort of facility 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297 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) There was delay in recognising that Mr Harnell was a most challenging patient for whom the usual means of discharge would not all be available. (2) There appears to have been delay in determining Mr Harnell's state of mental health (3) There appears to have been delay in approaching the Nursing Homes that may have been able to accommodate him. (4) There appears to be a lack of resources available for dealing with challenging (and vulnerable) patients like Mr Harnell. (5) There appears to be no guideline or protocol to assist staff on how best to deal with the discharge of patients like Mr Harnell. 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 17 November 2015. I, 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 copy of my report to the Chief Coroner and to the following interested Persons Mr | have also sent it to) Medical Director Plymouth Hospitals NHS Trust and Mr J Hunt MP who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. 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 telease or the publication of your response by the Chief Coroner. Dated 22 Septembey’d015 Assistant Cot Plymouth Torbay and South Devon 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297
3 responses 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 79 Whitehalf of Health London POCS 960072 smn Tel: 020 7210 4850 Mr A. Cox Assistant Coroner 20 OCT 2015 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ les Uy Cm Thank you for your My of 22"! September 2015, following the inquest into the death of William Harnell. I was extremely sorry to hear of Mr Harnell’s death and wish to extend my condolences to his family. This case highlights delays in the reporting of X-rays at Plymouth Hospitals NHS Trust, an issue that you were advised was a national problem and a direct consequence of a lack of qualified radiologists nationally. The timely reporting of X-rays is an important issue for patient safety. The Royal College of Radiologists (RCR) recognise this and advise that most X-rays and scans should receive a formal interpretation (report) within two days. In February 2015, the RCR carried out a survey' of NHS Trusts in England to understand the full extent of reporting delays in radiology departments and how long patients are waiting for results of their X-rays and scans. Key findings showed that whilst Radiology Departments were under pressure to minimise the number of unreported studies or lengthy waits for X-ray results, they faced challenges such as shortages of consultant radiologists, other resourcing issues and ever increasing demand. One of the recommendations in this report, (directed at Health Education England (HEE) and NHS England) was that more radiologists are recruited and trained. ' https://www.rer.ac.uk/sites/default/files/publication/Unreported studies Feb2015.pdf In addition, the report by the Independent Cancer Taskforce, Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020" recognises there is a shortage of radiologists across the country and makes the following recommendation on this issue: Recommendation 84: Health Education England should support improvements in the earlier diagnosis of cancer by working with the Royal College of Radiologists (RCR) and diagnostic experts in NHS England to review, on an annual basis, the number of radiology, diagnostic radiographers and nurse endoscopy training positions required to meet projected needs, and act urgently to address these needs. The Department of Health’s (DH) ALBs (including HEE) are considering the recommendations in this cancer strategy, and a response is expected in the autumn. HEE was established as the body to help improve the quality of care delivered to patients by ensuring that our future workforce is available in the right numbers with the right skills, values and competencies to meet their needs today and tomorrow. However, it is not responsible for setting curricular or the standards of training which is a duty for the regulatory bodies. My officials have liaised with HEE concerning the lack of radiologists nationally. I can advise that HEE will work with key partners, including the RCR, to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests. In particular, HEE will work with Public Health England and NHS England to ensure the availability, for example, of sufficient supply of qualified radiologists to ensure that X-ray results are reported in a timely manner, while taking account of the wider diagnostic service. To support this mandate, HEE is supporting a number of actions as part of its diagnostics workforce programme. A diagnostics workforce steering group, to be chaired by Professor Liz Hughes, Director of Education and Quality for London and South East, is being set up to provide overarching governance. In June 2014, the Centre for Workforce Intelligence (CfWI) was commissioned by DH and HEE to gather evidence on possible shortage occupations within the healthcare sector in England. A review of the Shortage Occupation List (SOL) was completed by the Migration Advisory Committee (MAC) and in April 2015, radiologists were added to SOL. 2 http://www.cancerresearchuk.org/sites/default/files/achieving world- class_cancer_outcomes -_a_ strategy for england 2015-2020.pdf The number of posts advertised in any specific year is dependent on the number of trainees successfully completing their training and thereby releasing their National Training Numbers (NTN) and post for a new trainee to fill. Reductions in recruitment numbers in a specific year in no way indicate, on their own, a reduction in the volume of training being commissioned. Over the last two years HEE have increased the number of training places available in radiology and in 2015, 212 training posts were advertised across England with a 100 per cent fill rate. Included in this number were 16 new posts established as part of HEE’s expansion in the specialty. At the last validated stocktake there were 952 clinical radiology trainees in England with a further 61 trainees on a break from training due to maternity leave or ‘Out of Programme’ learning or research experience. With a 5 year programme 952 would indicate an average output / intake of 190, delays and extensions to training will lower this average number. This level of training and associated CCT output has enabled the consultant radiology workforce to grow by over 70fte a year between 2009 and 2013. (2278 to 2561- as per HSCIC) HEE’s proposed education and training commissions for 2015/16 are set out in their second national workforce plan for England and can be found at: www.hee.nhs.uk/work-programmes/workforce-planning Iam grateful to you/for bringing the circumstances of Mr Harnell’s death to my attention and hop¢’that you find this reply helpful. Dr —_—_— BEN GUMMER
Plymouth Hospitals NHS) NHS Trust Dr Philip M Hughes MBBS MRCP FRCR Medical Director and Cons. Radiologist Chief Executive Office, Level 7 Derriford Hospital, Plymouth, Devon PL6 8DH Tel: 01752 432559 Fax: 0845 155 8228 E-nail: 12" November 2015 Mr A J Cox Assistant Coroner Plymouth, Torbay and South Devon 41 Derriford Park Plymouth PL6 3QZ Dear Mr Cox Re: Wittiam John Charles HARNELL In am responding in relation to a communication received from yourself on 22" September 2015 relating to Mr Harnell. The communication related to concerns arising from a recent inquest, which have been delivered to myself as the Medical Director, as part of Regulation 28, Schedule 5 of the Coroners and Justice Act 2009. In your letter, under sections 5 and 6, you raise 3 main concerns : 1. Delay in reporting of 5 days of the original pelvic radiograph. 2. A further delay of 2 to 3 days in obtaining a second pelvic radiograph. 3. Lack of perceived clarity by ward clinicians regarding the correct pathway to be used if x- rays are inconclusive in the context of potentiat hip injury. | will respond to these in order. 1. Delays in Reporting There are considerable challenges in the delivery of prompt plain film reporting on a 24/7 basis, due to the increasing demands on our diagnostic service. We have, however, reviewed our processes in relation to the Emergency Department and inpatients, and can now confirm that all Emergency Department films and inpatients from Sunday am and Friday 5pm, are reported within 24 hours through a revised reporting system. All weekend radiographs between 8am and 10pm will be reviewed by a senior ED physician. A limited number of overnight weekend films (Saturday and Sunday 10pm to 8am) will be reviewed on Monday morning. The maximum delay would be 60 hours for the Friday evening films. We are pursuing a further improvement, which would identify sub sets of films in the context of trauma, which could be reported within 24 hours on Saturday and Sunday, and will institute this if feasible. Working in Partnership with the Peninsula Medical School Chairman: Richard Crompton Chief Executive: Ann James 2. We are currently endeavouring, with the support of our service improvement team, to perform all radiographs on the day on which they are requested. We have seen a considerable improvement in this area in recent months and are now seeking to sustain this. 3. In relation to the MR protocol, we have developed a fast code for alt Radiologists, which reminds clinicians that a normal radiograph does not exclude a fracture and if there is faiture of pain-free weightbearing and radiographs are normal, an MR is indicated. We have also sent out a safety alert to all Physicians, which emphasises this point. We hope this gives some reassurance that the key issues identified through the inquest of Mr Harnell's are far less likely to occur in future. With regards. a Dr Philip M Hughes S MRCP FRCR Medical Director Working in Partnership with the Peninsula Madical School Chairman: Richard Crompton Chief Executive: Ann James
Mr AJ Cox Assistant Coroner Plymouth, Torbay & South Devon 1 Derriford Park Derriford Business Park PLYMOUTH PL6 5QZ Dear Mr Cox William John Charles HARNELL Your Ref: My Ref: Date: a a one and all fonen hag olf CORNWALL COUNCIL AJC/LH/LAW CL/CB 19 May 2016 Thank you for your letter of the 16 February 2016 to Trevor Doughty which has been passed to me for reply and also for your subsequent letter to me of the 5 May 2016. We received the copy of the Regulation 28 Report regarding Mr Harnell dated September 2015, in February this year. I can confirm that we have a dedicated Social Work Service working in Derriford Hospital and that staff have been reminded of the requirements to seek timely placements for people who need such placements. The staff working in the Hospital are dedicated and committed. These cases are often complex and need careful management. In response to the matters of concern cited in the Report: e The team in the Hospital works closely with Health colleagues to determine the appropriate care. The team will work with Health colleagues to seek mental health input as required for any future cases. e We acknowledge that on occasion there may be delays; however with our robust Senior Management oversight I do not expect such delays in future. e [can confirm that this Local Authority is able to fund placements that fall within its remit. e [note the comment about guidance to assist staff in such cases and am asking for this guidance to be produced and disseminated. I apologise for the further delay there has been in sending this reply. Please come back to me if you have any further queries Yours sincerely Head of Service Adult Care & Support Education, Health & Social Care Directorate Cornwall Council Tel: 01872 326899 i INVESTOR IN PEOPLE ( RECEVED 3 Ea epi MAY 2016 4 "CORONER SHOE as sipidel Konsel Kernow Cornwall Council, County Hall, Treyew Road, Truro, Cornwall TR1 3AY Tel: 0300 1234 100 www.cornwall.gov.uk
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