Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0500, written 12 Aug 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2015 |
|---|---|
| Reference | 2015-0500 |
| Deceased | Eileen Smith |
| Coroner | Edward Thomas |
| Coroner area | Hertfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Hertfordshire NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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CORONER’S OFFICE
DISTRICT OF HERTFORDSHIRE
The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES
DX: 100702 Hatfield
Tel: 01707 292780 Fax: 01707 897399
MR EDWARD G. THOMAS Senior Coroner MR GRAHAM DANBURY Deputy Coroner,
Dr FRANCES CRANFIELD, ALISON GRIEF, EDWARD SOLOMONS Assistant Coroners
12 August 2015
The Rt Hon Jeremy Hunt MP
Secretary of State for Health
Department of Health
79 Whitehall
London
SW1A 2NS
Your Ref:
Our Ref:
Dear Mr Hunt,
Re: Eileen SMITH, deceased
| am writing to you under the provisions of Schedule 5 (paragraph 7) of the Coroners & Justice
Act 2009 which came into force in July 2013. This re-enacted the provisions of the old Rule 43
of the Coroners Rules 1984. Attached to this letter is information concerning the new rules and
regulations from which you will see requires a written response. Copies of this letter and the
response received from you will be forwarded to the other interested persons identified at the
inquest in accordance with the list attached.
In fact | am aware that you had some knowledge of Eileen’s tragic death because the family
wrote to you and you kindly responded in July 2014 both formally and informally.
re
e
°
As you can see from the supplied documentation, Eileen had a learning disability the details of
which are fully contained in the findings and in the documentation supplied at the inquest.
Eileen was admitted initially to the Queen Elizabeth II Hospital Welwyn Garden City and then to
the Lister Hospital, Stevenage. With Eileen was a purple folder which detailed her disabilities
and her Health Action Plan. The Learning Disabilities Advisor from Health and Community
Services of Hertfordshire County Council gave me a specimen purple folder which would have
included Eileen’s Service User Plan and her personal care needs. The home where Eileen
resided also indicated that she never appeared cross or frustrated and never complained or
showed signs of discomfort or pain. She clearly very happy at the home and had an active life;
she was very supported by her family.
he. Page Two Eileen SMITH
The East and North Hertfordshire NHS Trust carried out a Serious Incident Investigation and
produced a report detailing failings including gross failings of nursing care. A detailed action
plan has been undertaken and | have been told that significant changes have been made to
prevent this from happening again. A copy of the report has been sent to the Clinical
Commissioning Group (CCG). The Trust has a policy concerning the care of adult patients with
learning disabilities and has now produced a hospital communications book to assist in medical
nursing staffs understanding of a person with learning disabilities. Towards the end of
paragraph 14 of my findings | felt it was important to state that assumptions about the health of
a person with learning disabilities could not be made by external appearances and that there
should be communication particularly with those such as carers and family who may well be
able to assist in helping the staff. This happened successfully on the first night of Eileen's
admission when the Senior Sister who clearly had read the purple folder contacted the family
who a Eileen to understand that she could not keep wandering from her room.
As | have indicated to the other interested persons, my primary purpose in making a Regulation
28 report to you, is to ask you whether you could assist in the care of persons with learning
disabilities. | was impressed by the purple folder, the passport that accompanies a patient to
hospital. The information contained can give those unfamiliar with the patient some
understanding of what to expect and not to make assumptions that when nothing is said that all
is okay.
The East and North Hertfordshire NHS Trust have undertaken a programme to assist staff in
achieving a greater understanding of patients with learning disabilities and the importance of
the Learning Disabilities Nurse whose service was notified by the Senior Sister on duty on the
first night.
The Health and Community Services of Hertfordshire County Council have informed me that
their department produced “my purple folder” as they were aware that persons with learning
disabilities can face obstacles in accessing support for their physical health needs including
communication difficulties which impacts upon their ability to secure appropriate advice. There
is no doubt in my mind that the “my purple folder” benefits all within the health and hospital
© environment and should be helpful in providing appropriate health care for learning disabled
patients. The Hertfordshire County Council have suggested to me that each acute Trust should
introduce or continue to use “Reasonable Adjustments Audit too! for each patient admitted with
learning disabilities to assess the adjustments made during their time in hospital and learn from
current practice in line with recommendations from guidance documents such as CIPOLD
Report. They tell me that they are piloting such a tool in the West Hertfordshire NHS Hospital
Trust (Watford General Hospital). They are planning to roll it out with the East and North
Hertfordshire Hospital NHS Trust (Lister Hospital) in the near future.
They have suggested to me that training should be mandatory for all staff within an acute
Trust:-
* Training as part of Trust Induction process on learning disability awareness and
reasonable adjustments including the use of “my purpie folder”
¢ Mandatory training on the role of paid/family carers in line with the Trust's Carers Policy
to ensure collaborative working across the Trust
« Training for all on the learning disabilities admissions policy and reasonable
adjustments including “my purple folder”
Cont'd
he. Page Three Eileen SMITH
* Training on Learning Disability Awareness the additional risk for patients with learning
disabilities and how they can be supported
The Hertfordshire County Council also has indicated to me that they feel the following would be
highly beneficial:-
e {dentification of a lead medical representative who can advise and work collaboratively
with Acute Liaison Nurses and clinical staff when a patient with learning disabilities is
admitted to the Trust.
e Investment in communication aids for all clinical areas, Hospital Communications Book
and Easy Read EIDO Leaflets to meet national information standards
| do not know whether “my Purple Folder” and “My Health Action Plan” are generally provided
throughout England and Wales in respect of persons with learning disabilities being admitted to
hospital but if it is not, then | would draw your attention to these suggestions in the hope that it
may then assist those with learning disabilities who are then admitted for what for them is likely
to be a strange and confusing environment. Comprehensive understanding of that patient will
undoubtedly benefit the care of that patient and hopefully prevent similar fatalities to that of
Eileen.
| heard so much about Eileen and was privileged to receive lovely photographs of her. She was
clearly a happy and lovely lady and as | indicated | find it very sad that she died in such
circumstances. | therefore hope that any other similar death can be prevented.
| look forward to hearing from you in due course.
Formally under Regulation 28 | require a response from you within 56 days of receipt which |
calculate is the Friday 9°" October 2015. | am retiring as Senior Coroner on the 31* October
2015 and would really appreciate a response within a reasonable timescale of that date to
enable me to communicate your response with the interested persons. Please let me know if
there are difficulties in complying with this timescale.
Many thanks for your anticipated assistance with this matter.
Yours sincerely
Senior 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.
AG Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of H ealth Richmond House 79 Whitehalf a London Mr E. Thomas SLALACIES Senior Coroner Tel: 020 7210 4850 The Old Courthouse St Albans Road East Hatfield Hertfordshire AL10 OES Dear Mr Thomas, Thank you for your letter of 12 August 2015 following the inquest into the death of Eileen Smith. I was extremely sorry to hear of Eileen’s death and the circumstances around it and wish to extend my sincerest condolences to her family. As you know, Jeremy Hunt wrote to her family last year. You explain that Miss Smith was a person with learning disabilities (LD) and that your primary purpose in issuing this Regulation 28 letter is to ask whether the Department can assist further in the care of persons with LD. A particularly worrying aspect of this case is the failure of nursing staff to escalate concerns about the patient, resulting in a lost opportunity for medical intervention. Following the death, the Trust carried out a Serious Incident Investigation and produced a report detailing failings, including gross failings of nursing care. A detailed action plan has been produced and changes made to prevent this failure from happening again. A copy of the report has been sent to the Clinical Commissioning Group. The Trust has also produced a hospital communications book which assists medical nursing staff in understanding patients with learning disabilities. I can advise that both the National Patient Safety Agency (NPSA) and the National Institute of Health and Care Excellence (NICE) have issued guidance in this area. Links are provided in the annex to this letter. NHS England is currently working on how better to escalate and respond to patient concerns. Work continues with the Royal College of Physicians to examine the system of care based around the Early Warning Score process. You mention the “purple folder” which accompanies a LD person to hospital and which contains details of their health record, their disabilities and a health action plan. The purple folder was produced by the Health and Community Services of Hertfordshire County Council (HCC) and is a tool that is used in the East and North Hertfordshire NHS Trust to improve the care of LD patients. You suggest that something similar should be deployed throughout England and Wales. The NHS in Wales is however the responsibility of the Welsh Assembly. In addition, the Council has suggested to you that each acute Trust should introduce, or continue to use, a “Reasonable Adjustments Audit Tool” for all LD patients admitted to hospital. I understand that HCC is currently piloting such a tool in Watford General Hospital and intends to implement it in the East and North Hertfordshire Hospital NHS Trust soon. HCC also suggests that training of staff in such things as LD awareness and risks, admissions policy, use of purple folder, reasonable adjustments and additional support should be mandatory for all acute Trust staff. The idea of a hospital type passport detailing the patient’s needs is familiar. For example, the Autism Passport has been developed by the National Autistic Society to help people with autism to communicate their needs to doctors, nurses and other healthcare professionals should they need hospital treatment. The purple folder system is similar to this but is intended for those patients with a learning disability who require hospital treatment. Introducing a ‘purple folder’ or similar system in the NHS is an operational matter for NHS England and individual NHS Trusts to consider. NHS England is aware of your letter and I am making an inquiry of them to gauge the urgency of their response. I welcome a better focus in hospitals on making reasonable adjustments to meet the care needs of patients admitted with learning disabilities. NHS England is currently working with commissioners, providers, third sector partners, families and experts to support this. ae Department of Health There are many other examples of good practice in preparing and treating hospital patients with a learning disability. These are promoted by NHS Choices, the General Medical Council (GMC) and Public Health England (PHE). Links to these resources are attached in the annex to this letter. J San comedy, Dr GS ALISTAIRBURT Ce David Behan CQC Annex -Links e NPSA: Recognising and responding appropriately to early signs of deterioration in hospitalised patients (NPSA): http://www.nrls.npsa.nhs.uk/resources/?entryid45=59834 e NICE: Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital (NICE CGS0): https://www.nice.org.uk/guidance/cg50/chapter/introduction e NHS Choices: Going into hospital with a learning disability: http://www.nhs.uk/Livewell/Childrenwithalearningdisability/Pages/Going- into-hospital-with-learning-disability.aspx e GMC: learning disabilities communication aids, health passports and hospital care: http://www.gmc-uk.org/learningdisabilities/333 aspx e PHE: Reasonable Adjustments Database - includes examples of health and hospital passports, and the purple folder, in use across various NHS Trusts: https://www.improvinghealthandlives.org.uk/adjustments/?adjustmenttype 0 e PHE: Working together 2: Easy steps to improve support for people with learning disabilities in hospital - guidance that incorporates approaches by hospitals, paid carers and families: https://www.improvinghealthandlives.org.uk/publications/1247/Working togeth er_2: Easy steps to_improve support_for_people_with learning disabilities i n_hospital
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