Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0464, written 17 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 | 17 Nov 2015 |
|---|---|
| Reference | 2015-0464 |
| Deceased | Frank Mellers |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 2. Care Quality Commission (CQC). | i | 1. Chief Executive NHS Foundation Trust (Walsalf Manor Hospital) | | CORONER | i | lam Mr Zafar Siddique, Senior Coroner, for the coroner area of Black Country. (2 | CORONER'S LEGAL POWERS i | | 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 23 September 2015, | commenced an investigation into the death of Mr Frank Mellers (dob 18/9/21). The investigation concluded at the end of the inquest on 17 November 2015. The conclusion of the inquest was a narrative conclusion: | Mr Meliers had a fall at home on the 4 September 2015 and sustained a fractured left i i hip. He was admitted to Hospital the same day and had an operation to repair the fracture on the 16 September 2015. Post operatively he initially made good recovery and a do not attempt resuscitation notice (DNAR) was in place prior to surgery. There | were a number of occasions of poor communication with the family of the deceased ! where little or no explanation was given to the family as to his actual DNAR status. In | addition he was thought to be not classified as DNAR by nursing staff and CPR was commenced when his condition declined and he suffered a cardiac arrest on the 17 | September 2015. He was initially resuscitated and then had a further heart attack and | | on this second occasion, CPR was not commenced and he died on the 17 September 2015 as a result of congestive cardiac failure, Ischaemic heart disease contributed to by | the stress of the necessary operation to repair the fracture.” i The medical cause of death was 1a) Congestive cardiac failure 1b} ischaemic heart disease 1c) Post-operative repair of fracture neck of femur. The circumstances are apparent from the conclusion outlined above. 4 | CIRCUMSTANCES OF THE DEATH | / | CORONER'S CONCERNS on | 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) Evidence emerging from the inquest suggested that the patient's ONAR status i fILt: PROTECT] that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with ali such decisions. T i | | | (2) There was generally poor communication between nursing and medical staff as i evidenced during the inquest when a decision was made to attempt | | resuscitation despite there being a DNAR in place. | | | | i if | (3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. 6 | 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. 7 | YOUR RESPONSE | | You are under a duty to respond to this report within 56 days of the date of this report, | namely by 11 January 2016. |, 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. |8 | COPIES and PUBLICATION i have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Mr Meller’s family. | | 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. 9 17 November 2015 Vag © we a (IL: PROTECT) be
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.
Walsall Healthcare INHS NHS Trust Our Ret: Patient Safety Department Your Ref: Manor Hospital Moat Road Date: 08 January 2016 Walsall West Midlands. WS2 9PS Mr Z Siddique Tel: 01922 721172 ext 7481/7482/7354 HM Coroner's Office Email: Crocketts Lane Website: www. walsallhealthcare.nhs.uk Smethwick —_—_———e—ee—— B66 3BS Dear Mr Siddique Re: Frank Mellers deceased Date of Birth: 18" September 1921 Date of Death: 17" September 2015 Date of Inquest: 17° November 2015 1 am writing in response to your report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | would like to assure you that as a result of the Inquest findings, Mr Mellers’ case was formally reported and investigated as a Serious Incident. As an organisation we have formal processes for investigating Serious Incidents. To this end, a Root Cause Analysis was completed which included a review of the systems in place for maintaining safety at the time. The learning from both the Inquest and the internal investigation will be shared with staff across the organisation. Summary of Incident Mr Mellers arrived via the Emergency Department on 14" September 2015 following a mechanical fall at home. As a result of this fall, Mr Mellers was identified as having sustained a fracture to the left neck of femur for which he underwent a hemi-arthroplasty procedure. Pre operatively, a Do Not Attempt Cardio Pulmonary Resuscitation (DNAR) document had been completed and discussed with Mr Mellers following concerns raised about the effect anesthesia during surgery would have. A telephone call was made to Mr Mellers’ Grand Daughter to inform her of the risks associated with the surgery. Mr Mellers surgery was carried out on 16 September 2015 and is noted to have progressed well with no immediate concerns noted. Mr Mellers was identified to be recovering well and returned to the ward the same day. Through the night, Mr Mellers is noted to have reducing blood pressure, oxygen saturation and temperature for which interventions were put in place to support him, Mr Mellers is recorded as appearing comfortable and reporting no increase in pain at that time. On 17 September 2015, a call was made for the cardiac arrest team to attend to Mr Mellers; they did this and were able to regain pulse. However, following this, Mr Mellers experienced a second arrest anda decision was made to abandon the resuscitation as the team realised that there was a DNAR in place. Mr Mellers was recorded as dying at 12:2Ohrs. Page 2 Coroner’s Concerns During the course of the inquest the evidence revealed matters giving rise to concern. In the Coroner's opinion there is a risk that future deaths will occur unless action is taken. The MATTERS OF CONCERN are as follows. — 1. Evidence emerging from the inquest suggested that the patients DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice guidelines require that the family be kept up to date with all such decisions. 2. There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place. 3. In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined. Action Taken A Root Cause Analysis was undertaken following Mr Mellers Inquest and action has been taken with regard to communication with patient's families and between nursing and medical teams about DNAR. The following actions have been taken: e We have reiterated the importance of the use of our ward round standard which emphasises the importance of daily ward rounds to be carried out between both staff groups to ensure strong and robust care management. e We have developed an indicator on our Ward Boards to ensure that where a patient has a DNAR in place it is highlighted to all staff. The Ward Boards act as a communication tool to allow for fast reference by all staff groups during handovers and during the course of the day. e We reviewed our policy to ensure that it is compliant with best practice (including communication) with regard to DNAR. e We have developed a leaflet to provide patients and families with information about DNAR (enc). ¢ The findings of Mr Mellers Inquest have been shared with relevant staff, including all Consultants. e We have undertaken over the past several months a series of peer audits throughout a variety of care settings to review the effectiveness with which DNAR forms are being utilised. | am pleased to report that during this period we have seen significant improvements in the quality, completeness and robustness of the use of DNAR with particular emphasis placed upon ensuring discussions with patients and their families are clear and fully documented about the purpose and potential outcome of a DNAR. We will be carrying out these audits and reviews on a rolling basis to assure that the learning from this incident which we have disseminated across our organisation. Finally, may we take this opportunity to offer our unreserved apologies to Mr Mellers family along with our sincere condolences for their loss. Yours sincerel Amir IS Medical Director
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