Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0437, written 11 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2015 |
|---|---|
| Reference | 2015-0437 |
| Deceased | David White |
| Coroner | Jacqueline Devonish |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health 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:
1. EE tiodicai virector, Barts Health NHS Trust
CORONER
! am Jacqueline Devonish, assistant coroner, for the coroner area of Inner North London
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.
INVESTIGATION and INQUEST
On 10 November 2015 | commenced an investigation into the death of David Alan
White. The investigation concluded at the end of the inquest on 10 November 2015. The
conclusion of the inquest was accident contributed to by neglect with a medical cause of
death as follows:
1a Bronchopneumonia and acute on chronic transplant kidney failure
1b Valvular, ischaemic and hypertensive heart disease, right foot ischaemia and
fractured neck of right femur.
CIRCUMSTANCES OF THE DEATH
Mr White was admitted to the Royal London Hospital on 11 June 2015, where he
remained until his death on 26" June. The original admission followed a presentation to
the GP with significant pain from his arterial vascular disease on 4 June.
On admission to hospital his Warfarin was changed to Heparin, and the family informed
the nurses that this had led to confusion and hallucinations for Mr White.
On 12 June 2015 the hospital records demonstrate that Mr White had been risk
assessed for mobility, and that the following actions had been agreed:
1. Call bell to be within reach
2. Supervised transfers
3. Physiotherapy and Occupational Therapy
At 21:40 hours on 18 June 2015 Mr White sustained an unwitnessed fall on the ward.
He said that he fell backwards onto his bed when reaching for a urine bottle. He was not
injured. His care plan was reviewed and the bedsides rails decision was reviewed.
At 08:45 hours on 19 June 2015 Mr White sustained another unwitnessed fall, He was
found lying on the floor. He explained that he had slipped when attempting to get
something out of the bedside locker. X-rays revealed a right hip and right shoulder
fracture, but did not identify fractured ribs, predominant! ght side.
On 21 June 2015 he underwent emergency surgery for the fractured right neck of femur.
Following surgery he was admitted to the intensive care unit where he remained
intubated and ventilated, in addition to being on a Hemofilter. On 24 June 2015 he was
stepped down to the Renal High Dependency unit, but remained unwell with a likely
infected dialysis catheter. He died on 26 June 2015 at 21:55 hours.
COR ’ CERNS
Ouring 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) The effect of Heparin, in causing confusion, was not in the records, and therefore not
acted upon.
(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but
there was no supervision arrangement in place. One to one care had been in
contemplation.
(3) Whilst nursing notes were being kept about the risks, the records were not being
reviewed and acted upon.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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 15 January 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
Person, eee
lam 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.
11 November 2015 a : {
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.
Barts Health NHS Trust Trust Executive Offices Ground floor, Pathology Block The Royal London Hospital London, E1 2ES Telephone: 020 32460632 www.bartshealth.nhs.uk Ms Jacqueline Devonish Assistant Coroner for Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 13 January 2016 By special delivery Dear Ma’am, Inquest touching the death of David Alan White I write in response to a Regulation 28, Report to Prevent Future Deaths, dated 11 November 2015, which was made at the conclusion of the inquest into the sad death of David White. Barts Health NHS Trust takes Coronial investigations very seriously and I am sorry you have had to make Preventing Future Death recommendations and I am grateful to you for highlighting your concerns. I note David Alan White died after suffering a fractured neck of right femur following an unwitnessed fall on the ward and your concerns relate to the lack of nursing documentation and lack of care plan review relating to his mobility. The concerns you have raised in the Preventing Future Death report are: 1. The effect of Heparin, in causing confusion, was not in the records, and therefore not acted upon. 2. Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation. 3. Whilst nursing notes were being kept about the risks, the records were not being reviewed and acted upon. We have investigated the above concerns and I can confirm: 1. The members of staff have been reminded of the importance of adhering to the normal process of ‘documenting allergies and adverse effects’ regardless of how unique the reaction may be as in this case. This issue has also been discussed in the Renal Mortality and Morbidity meeting as a learning point for all teams and members of staff on the importance of documenting drug- related issues and the escalation of this information to senior clinical staff. 2. The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan. It has been emphasised to all senior nursing staff that daily auditing of all nursing and falls risk documentation must be carried out. This will ensure that call bells are within reach of patients and that all assessments and any changes in care plans are highlighted in the medical records. We have reviewed the escalation of our ‘Specials’ requests to Bank Partners so that patients can be appropriately monitored and supervised (one to one) when they are assessed as at risk of falls and/or confused. Site managers can now be contacted out of hours to ensure appropriate management of care. 3. Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls. This meeting consists of medical/surgical teams, physiotherapy, Occupational Therapists and the Ward Nurse in charge and includes a medical handover to ensure communication of any deterioration overnight that could influence risk of falls, such as increased confusion. A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015. I am once again grateful to you for bringing this case to my attention and I hope this letter fully answers the concerns you have raised. Yours faithfully Professor Joanne Martin Medical Director Barts Health NHS Trust
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