Prevention of Future Deaths reports · 2016
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 report | 28 Jul 2016 |
|---|---|
| Reference | 2016 – 0272 |
| Deceased | Leslie Morrison |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Central Manchester University Hospitals NHS Foundation 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:
¢ 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.
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.
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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