Prevention of Future Deaths reports · 2016

Leslie Morrison

Regulation 28 report to prevent future deaths, reference 2016 – 0272, written 28 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report28 Jul 2016
Reference2016 – 0272
DeceasedLeslie Morrison
CoronerNigel Meadows
Coroner areaManchester City
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedCentral Manchester University Hospitals NHS Foundation 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:

¢ HE Medical Director, Manchester Mental Health and

| Medical Director, Central Manchester
University Hospitals NHS Foundation Trust
e Ms S Foxall-Smith, Chief Executive, Regard Care

Copied for interest to:
e Chief Executive of NHS Clinical Commissioning Groups,
Manchester
e Care Quality Commission
e Creative Support

1 | CORONER

| am Nigel Meadows, H.M. Senior Coroner for the area of Manchester
City.

2 | 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.

3 | INQUEST

On 8 January 2015 | commenced an investigation into the death of Leslie
John Morrison, aged 82. The investigation concluded at the end of the
inquest on 26 July 2016.

The cause of death was found to be:
la Respiratory and cardiac arrest
1b Acute aspiration of food
ll Ischaemic heart disease and cerebrovascular disease

The conclusion of the inquest was Accident.

CIRCUMSTANCES OF THE DEATH

The deceased was 82 years of age and had been born on 21 January
1932. He suffered a chronic enduring mental health condition, namely
bipolar disorder. He had been treated for many years with medication to
control the condition and had previous informal admissions to psychiatric
units. He also suffered from a number of other physical conditions,
including atrial fibrillation, bundle branch block, postural hypotension, an
abdominal aortic aneurysm, overactive bladder syndrome and
osteoarthritis.

He had a supportive and caring family, together with the assistance of a
Registered Mental Nurse who acted as his care co-ordinator. In about
2010 he moved to 299 Great Western Street, Rusholme, Manchester,
which is supported care accommodation provided by Regard Care. He
required 24 hour care and support to meet his considerable needs.

Over a period of time, his physical condition deteriorated and on or about
5 June 2014 he suffered a choking episode when eating a meal. He was
admitted to hospital and underwent a procedure to remove an airway
obstruction which apparenily turned out to be a sprout. His care co-
ordinator then requested a SALT swallowing assessment to be
undertaken, which resulted in specialist advice that he required a soft diet
with supervision during and for 30 minutes following a meal. Advice was
also given about the oral ingestion of a number of medication tablets that
he was required to take, which needed to be consumed individually with
some lubrication. His care plan was altered to specifically record the
SALT assessment and recommended regime of supervision and
management.

Over the autumn of 2014, his mental health condition deteriorated and his
psychiatrist was in the process of reviewing and altering his medication,
as he was suffering from persistent low mood. He had a history of
imbalance and falls. He required supervision and assistance with all day
to day activities, and in particular his personal hygiene. He suffered no
further episodes of choking during this period.

On 1 December 2014, he had a dizzy episode and fell to the floor in the
shower whilst being supervised. He was admitted to Manchester Royal
Infirmary and was seen and assessed originally in the Acute Medical Unit.
It was unclear if he had been accompanied to hospital by a carer, but
there is no evidence that his detailed care plan accompanied him, and no
specific information was provided to the hospital about any particular
condition or management in the community.

The investigations ruled out any major emergency pathology, but there
was evidence that he was suffering from an infection and he was started
on antibiotics. He was then transferred to Ward 46. He was initially
moved there on 3 December by one of the junior doctors and his
condition appeared to be stable and his Early Warning Scores were 0.

On 4 December he was reviewed by a Consultant Physician, who formed
the clinical opinion that he was suffering from both a urinary tract and
chest infection and his antibiotics were altered. Thereafter his condition
remained stable, and gradually improved. Over the next few days the
markers for infection reduced, and by 10 December he was considered to
be fit enough to be discharged back into the community.

At approximately 1230hrs, he was given an egg mayonnaise sandwich,
which had to be taken out of its wrapper by a member of staff, and he
was left to eat this unsupervised. About 15 minutes later, he was found in
a slumped position on the table with evidence of cyanosis. The
emergency buzzer was pulled and immediately the nurse and a junior
doctor attempted to begin CPR and remove some food debris from the
mouth pending the arrival of the crash team. They arrived very shortly
thereafter and further food debris was removed from his upper
airways/throat area. Unfortunately their attempts at resuscitation proved
unsuccessful and he was pronounced deceased shortly before 1300hrs.

A subsequent post mortem examination established that he died as a
result of an acute aspiration of food.

It was apparent from the evidence received by the court that he lacked
mental capacity, but was not subject to a DoLS authorisation in the
community, nor indeed was it even considered or applied for whilst in
hospital. Prior to 10 December 2014, during his last admission, he did
not apparently demonstrate any difficulties with consuming food orally.
Nor was it noted or recognised that he actually lacked mental capacity.
Had the hospital been aware of his SALT assessment, they would have
adopted that aspect of his care plan and arranged for a further SALT
assessment.

His care co-ordinator was aware of his admission but presumed that his
carers would have supplied a copy of his care plan or details of his SALT
assessment. She did not contact the hospital direct or his carers to check
this. She was not contacted by the hospital nor his carers to check any
aspect of his medical history.

His carers did not provide the hospital with a copy of his care plan, and in
particular details of his SALT assessment. Nor did the hospital

communicate with either his GP, his care co-ordinator or his carers to
request any information.

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. Although it is appreciated that the events in question occurred later
in 2014 following the Cheshire West case, it is a matter of concern
that in the community, no formal mental capacity assessment was
undertaken and no consideration of a DoLS authorisation was
undertaken.

2. Consequently, upon his admission to hospital, it was not
recognised that he lacked mental capacity. There was no formal
assessment and he was treated as an ordinary patient.

3. Details of his mental health condition and in particular his care plan
did not accompany him and/or were not supplied by his carers or
his care co-ordinator to the hospital, but nor did the hospital check
or request information from those looking after him in the
community. The concern is that in this case, the deceased’s death
was avoidable and had there been appropriate communication
between all those looking after him, steps would have been taken
to ensure his oral diet complied with his current SALT assessment
pending a review. It is suggested that the Hospital Trust, the
Mental Heaith Trust and any caring organisation (whether that be a
charity or a private organisation) should have policies and
protocols which are applied to ensure that up to date information is
provided upon admission to or discharge from hospital.

6 | 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.

1. {tis suggested that the Hospital Trust, the Mental Health Trust and
any caring organisation (whether that be a charity or a private
organisation) should have policies and protocols which are applied
to ensure that up to date information about patients’ particular
conditions (both mental and physical) are supplied between those
caring for the patient when they are admitted to hospital when they
are admitted, and back into the community when they are
discharged.

2. Itis suggested that in practice on admission to hospital and
appropriate review of a patient’s records and care plan should
trigger a mental capacity assessment and an application for DoLS
authorisation if appropriate.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by 30 September 2016. 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

| have sent a copy of my report to the Chief Coroner and to Interested
Persons. | have also sent it to organisations 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.

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 Respondent Not Named (PDF)
Room 217 
Medical Directors Office 
Trust Headquarters 
Manchester Royal Infirmary 
Oxford Road 
                                                                                                                Manchester  
M13 9WL 
Tel:  0161 276 4840 
Email: robert.pearson@cmft.nhs.uk 

Mr Meadows  
HM Coroner’s Office - Manchester City Area 
PO Box 532 
Manchester Town Hall 
Albert Square 
Manchester 
M60 2LA   

Tuesday 30th August 2016  

Dear Mr Meadows 

Re:  Mr Leslie Morrison – Regulation 28: Report to Prevent Future Deaths  

I  have  now  had  the  opportunity  to  look  into  the  concerns  you  raise  in  respect  of  this  case. 
The response required from Central Manchester University Hospitals NHS Foundation Trust 
was relating to two specific points:  

1.  It is suggested that the Hospital Trust, the Mental Health Trust and any caring 

organisation should have policies and protocols which are applied to ensure that up 
to date information about patients particular conditions (both mental and physical) are 
supplied between those caring for the patient when they are admitted to hospital, and 
back into the community when they are discharged. 

2.  It  is  suggested  that  in  practice  on  admission  to  hospital  an  appropriate  review  of  a 
patient’s records and care plan should trigger a mental capacity assessment and an 
application for a DoLS authorisation if appropriate.  

For ease I will respond to each of your points in turn.  

You note that on Mr Morrison’s admission to the  Manchester Royal Infirmary his carers did 
not  provide  an  up  to  date  care  plan,  and  the  acute  hospital  staff  did  not  actively  seek  to 
receive a copy of his care plan from either his carers or primary care.  

Whilst  in  the  community  Mr  Morrison  had  been  assessed  by  the  Speech  and  Language 
Team as requiring supervision whilst eating, and for a period of 30 minutes after to ensure 
that he remained safe. As this information was not passed on to the acute team this was not 
continued whilst he was in hospital. The admission documentation and nursing assessments 
on the Acute Medical Unit when Mr Morrison was admitted note that he took diet and fluids 
normally and was not noted to have any swallowing difficulties; as a result of this no referrals 
were  made  for  a  Speech  and  Language  Therapy  assessment.  He  was  however  on  a  soft 
diet,  and  having  discussed  this  with  the  Speech  and  Language  Therapy  team,  they  have 
confirmed that an egg mayonnaise sandwich would be acceptable as part of a “soft normal 
diet” with the caveat that if the bread had a hard crust, the crust would need to be cut off. 
Had  the  acute  team  received,  or  actively  sought  out,  information  regarding  Mr  Morrison’s 

 
 
 
 
 
 
 
 
 
 
 
 
 
 nutritional care plan and feeding requirements, the 30 minute observation period would have 
been  implemented  which  may  have  meant  that  he  received  more  timely  intervention  when 
he aspirated after eating.   

With regards to the handover of information between care environments, I am in agreement 
that  it  is  a  matter  of  good  practice  to  hand  over  all  salient  care  issue.  This  is  universally 
accepted in the NHS and there are many examples of good practice guidance available for 
this  purpose.  Achieving  effective  and  safe  hand  over  in  all  circumstances,  particularly  for 
complex  and  vulnerable  cases,  remains  a  considerable  concern  in  all  parts  of  the  public 
health and social care sector.  

It is accurate to say that handover between acute and community services, and vice versa, 
for all vulnerable adults remains at times of an inadequate quality and consistency, as was 
the  case  for  Mr  Morrison.  Remedy  for  this  is  a  system  wide  problem  however  we  need  to 
take local responsibility for ensuring that this takes place for patients within our care.   

Currently  as  a  Trust  we  do  not  have  a  formal  policy  in  place  for  the  sharing  of  up  to  date 
information  for  patients  who  are  vulnerable  or  have  complex  conditions.  Whilst  staff  will 
informally  liaise  with  care  agencies  or  primary  care,  this  is  ad  hoc  and  not  an  embedded 
process  therefore  relies  on  the  staff  providing  care  to  a  patient  to  proactively  consider  the 
information  that  may  be  held  elsewhere.  There  are  exceptions  to  this  however,  such  as 
patients with learning disabilities, where there is a formal process in place through the use of 
their LD passport; however this is not consistent across other patient groups. As a result of 
the findings of this case we will implement a Trustwide initiative regarding the development 
of  a  policy  or  pathway  for  complex  and  vulnerable  patients  which  will  include  proactively 
gathering  information  from  health  providers  outside  of  the  Trust.  This  will  include 
representation  from  all  of  our  hospitals  and  Divisions  to  ensure  that  this  is  implemented 
across all of our services.  

You  also  note  in  your  letter  that  it  was  apparent  that  Mr  Morrison  lacked  mental  capacity 
however a DoLS application was not completed whilst he was in the community or whilst in 
was an in-patient at the Manchester Royal Infirmary.  

As I am sure you are aware, mental capacity (as defined in the Mental Capacity Act 2005) is 
decision specific and a finding of ‘lack of mental capacity’ alone is not sufficient to justify a 
DOLS  emergency  or  standard  authorisation.  This  requires  a  finding  of  lack  of  mental 
capacity  to  make  decisions  about  location  and  manner  of  care  and  judgement  about  the 
specific manner of care in place at the material time. With regards to a DOLS emergency or 
standard authorisation, this is about the manner in which a person is cared for not about the 
care provided per se.  It is therefore a matter of judgement for the responsible person with 
overall  responsibility  for the  environment  in  which a person is  cared for, to decide  whether 
there has been or is a risk of an Article 5 breach in which case authorisation can be sought.  

Currently when patients are admitted to the hospital an assessment is made as to whether 
there are any apparent concerns with their ability to make decisions about their care, in order 
to ensure that we are providing the most appropriate care for patients.  This is an on-going 
process  and  can  be  both  formal  and  informal  to  ascertain  if  a  patient  understands  where 
they  are  and  what  is  happening  to  them,  and  if  they  can  consent  to  whatever  care  and 
treatment  is  being  undertaken.  If  there  is  any  doubt  about  their  inability  to  understand, 
consent  to  treatment  or  make  decisions  about  their  care  and  treatment,  a  mental  capacity 
assessment will be completed which will be decision specific. This will support staff to make 
appropriate decisions about whether a patient lacks capacity. If it is assessed that a patient 
lacks  capacity,  it  will  be  ascertained  if  additional  safeguards  are  needed  and  if  these 
additional restrictions and/or restraint used would deprive a person of their liberty. If this was 

 
 
 
 
 
 
 
 
 
 the case then a Deprivation of Liberty Safeguard application would be made. 

The Trust is in the process of implementing a transformation project regarding a delirium tool 
and a frailty flag to help identify those patients who may have reduced capacity. The Trust 
are working with Patientrack, our partners for the electronic Early Warning Score system, to 
embed a frailty screen in patients aged over 75 which would then identify patients requiring a 
comprehensive geriatric assessment. The next stage would be to embed a delirium screen 
into  Patientrack.  This  work  continues  to  progress  and  currently  a  pilot  of  frailty  screening, 
CGA  and  delirium  screening  is  taking  place  at  our  Trafford  site,  from  which  the  initial 
feedback  is  positive.  This  will  then  be  developed  to  produce  a  unified  tool  across  Trafford 
and central site and support the care provided to our vulnerable, frail and elderly population.  

With regards to staff training around mental capacity and DoLS, I can confirm that we have 
monthly  DoLS  training  sessions  in  place  regarding  awareness  of  the  process  and  the 
completion  of  DoLS  and  mental  capacity  assessments.  In  addition  there  have  also  been 
sessions arranged with our Solicitor partnership firm for external training sessions to be held.  

In addition we also mandate within the Trust that all registered nurses complete level 3 Adult 
Safeguarding training, which is the most advanced safeguarding training we offer clinicians; 
DoLS and mental capacity is covered within the body of this training. The safeguarding team 
also  offer  bespoke  sessions  to  areas  who  require  further  support  or  detail  regarding  the 
completion of DoLS.   

We  are  also  considering  the  inclusion  of  safeguarding  at  each  of  our  quarterly  Audit  and 
Clinical Effectiveness Days, focusing in particular on DoLS and mental capacity. This will be 
discussed further and plans for implementation made.   

Moving  forward  and  in  order  to  improve  the  consideration  given  to  mental  capacity 
assessments  and  DoLS  authorisations,  your  letter  will  be  discussed  at  the  Trust  Clinical 
Effectiveness Committee to note your concerns and consider how this should be addressed. 
Any  further  action  will  then  be  monitored  via  this  committee  and  allocated  to  the  relevant 
leads.  

Please  accept  my  assurances  that  lessons  have  been  learned  from  this  case  and 
appropriate  actions  have  been  put  in  place  to  address  the  issues  that  you  raise.  I  am 
confident that these actions will lead to improvements in the care we provide to our patients, 
particularly those that are vulnerable or have complex conditions. 

Yours sincerely 

Professor R C Pearson 
Medical Director & Caldicott Guardian 
MAHSC Honorary Clinical Professor, University of Manchester

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