Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0279, written 1 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2016 |
|---|---|
| Reference | 2016 – 0279 |
| Deceased | Pamela Gressman |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Tees, Esk and Wear Valley 1 CORONER I am Andrew Tweddle Senior Coroner, for the coroner area of County Durham and Darlington. 2 CORONER’S LEGAL POWERS 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. (see attached sheet) 3 INVESTIGATION and INQUEST On 9th March 2016 I commenced an investigation into the death of Pamela Gressman, 65 years. The investigation concluded at the end of the inquest on 1st August 2016. The conclusion of the inquest was a narrative- The result of ingesting a number of foreign bodies, one or more of which led to a perforation of the colon. The medical cause of death was; 1a) Hospital Acquired Pneumonia, 1b) Colonic Perforation, 1c) Ingested Foreign Body, 2) Depression, Laparotomy with Sigmoid Colectomy & Formation of Stoma, Bleeding Duodenal Ulcer, Malnutrition, Diet Controlled Diabetes, Previous Stroke, Ischaemic Heart Disease, Chronic Obstructive Pulmonary Disease. 4 CIRCUMSTANCES OF THE DEATH The deceased at some time ingested a series of foreign bodies which were found internally during an operation. She had been admitted as a voluntary patient to West Park Hospital, Darlington. It is unknown when the items which were found within her during the operation were ingested. It is not known whether she had actually ingested all or any of the items which she said she had ingested which led to her being admitted to hospital in January 2016. She reported abdominal pains which were not associated to be linked with the swallowing of foreign bodies. The Consultant Psychiatrist did not believe that she had swallowed foreign bodies during the period of admission to the hospital and that she probably swallowed various items prior to admission. During her period of admission there is no documented enquiry having been made as to how physically well she was in relation to the items which she had allegedly swallowed nor was any consideration given to discussing with her whether such items had been passed naturally from her body nor was any system in place to be able to monitor if and when any foreign bodies were excreted from her body. It is possible that such foreign bodies within her system could remain benign for a period but likewise could move and cause serious harm or become life threatening. There is nothing to suggest that this important matter was given any significant consideration by those responsible for her care. 5 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. – Whilst it is clear that considerable attention was given to the deceased’s mental health, insufficient consideration or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had and which led to her period of hospitalisation. Thus little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. The absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 Tuesday 27th 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons and the Care Quality Commission. I 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 [DATE] [SIGNED BY 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.
Tees, Esk and Wear Valleys NHS} 27" September 2016 Mr A Tweddle H.M. Coroner, County Durham and Darlington H.M. Coroners Office PO Box 282 Bishop Auckland County Durham DL14 4FY Dear Mr Tweddle Re: Pamela Gressman, deceased Regulation 28 Report NHS Foundation Trust West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS Direct ma Further to your letter 2 August 2016, | write to detail the actions we have taken relating to the concerns you identified during the inquest into Pamela Gressman’s death. You identified that you felt insufficient or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had, and which led to her period of hospitalisation, leading to the conclusion that little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. You felt that the absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future. The Trusts internal serious incident report identified root and contributory causes resulting in a number of actions being progressed. We have now had the opportunity to review your findings and have outlined below the actions taken to date and those we are putting in place to reduce the risk of a similar incident occurring in the future: e The findings and lessons learned from the internal investigation and inquest have been shared in detail with the ward multidisciplinary team, which continue through a variety of means across the Trust. To be completed 30" September 2016 Chairman Lesley Bessant Chief Executive Cola Martin. ©) INVESTORS. Trast headquarters West Park Hospital, Edward Pease Way. Darlington, DL2 21S IN PEOPLE Tees, Esk and Wear Valleys NHS} NHS Foundation Trust e A review of the observation and engagement procedure will include consideration of a period of enhanced observations for a period of time following ingestion of a foreign object to enable close monitoring of any physical side effects but also to monitor if any foreign bodies are passed through stools. Completed e Further case discussion and lessons learned from the incident is being held with all inpatient Consultant Psychiatrists and Modern Matrons. To be completed 31° October 2016. e Additional training requirements identified for staff around the use of the Early Warming Signs (EWS) process in particular. Individual clinical supervision sessions are taking place to reinforce EWS and physical health monitoring processes with the ward staff, including that staff must not just record any deterioration but take action on this through seeking prompt medical advice. Completed e Formal training sessions to be delivered to specifically include: o Consideration of the possibility of physical effects (sometimes delayed for days) following swallowing of foreign objects, in particular for patients with known history of this o Clarification of process to check if foreign bodies have been passed in stools by patient o The requirement to have a risk management plan and intervention plan to monitor and manage physical health care symptoms of concern and the need to record related observations (10 case notes to be audited). To be completed 31° October 2016 (delayed due to the challenges of delivering training during the holiday period). e An SBARD (notification document) has been developed for all staff Trustwide in relation to improving patient safety and minimising the risk of a repeat incident. Completed. e Recruitment of a Physical Health Practitioner for the West Park site to provide additional support, skill and expertise to ward teams. Recruitment to commence September 2016. e Liaison colleagues to work with the local Emergency Department to ensure standard work is designed and shared to ensure X-rays are done of thorax and abdomen in such instances. To be completed by 31°' October 2016. The Directorate Quality Assurance Group will also ensure that the lessons learnt are shared across other inpatient areas so they can assure us that similar issues should not occur elsewhere. The Trust has corporate processes to both monitor completion 2 Tees, Esk and Wear Valleys NHS Foundation Trust of serious incident action plans and to audit the effectiveness of those actions in creating change and improvement. | hope that the information contained here, and in the action plan attached, provides you with the necessary assurance you require. Yours sincerely Mla Mell Colin Martin Chief Executive
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