Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0286, written 12 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 | 12 Aug 2016 |
|---|---|
| Reference | 2016 – 0286 |
| Deceased | Jean Stockley |
| Coroner | Karen Harrold |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr Gillian Fairfield Chief Executive Royal Sussex County Hospital Eastern Road Brighton BN2 5BE CORONER | am Karen Harrold, Assistant Coroner for the coroner area of West Sussex. }__ 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5 http://www. legislation.gov.uk/uksi/2013/1629/made ol INVESTIGATION and INQUEST On 20th April 2015 the Senior Coroner, Penny Schofied, commenced an investigation into the death of Jean Stockley aged 84 years old. The investigation concluded at the end of the inquest on 2 August 2016. | recorded a conclusion of Accidental Death and the medical cause of death as: 1a) Respiratory failure; 1b) Bilateral pneumonia; 1c) Traumatic spinal fractures; 2) Asthma, Elevated right hemi-diaphragm. CIRCUMSTANCES OF THE DEATH Jean Stockley was admitted to the Royal Sussex County Hospital in Brighton on 17th March 2015 following an unwitnessed fall at her son's home when she fell down 13 stairs landing on her back and neck. The immediate focus was on establishing any orthopaedic problems and after MRI/CT scans it was confirmed that she had one fracture in her neck and three in her thoracic spine. She was admitted to an orthopaedic ward and her management was referred to a neurological registrar who confirmed that surgery was not felt to be appropriate and that initially, a brace and collar was the preferred treatment. Due to breathing difficulties, treatment of the spinal injuries was changed to conservative management. Mrs Stockley had pre-existing COPD/asthma and used an inhaler. During her stay in hospital the plan to manage her respiratory condition included treatment and therapy from physiotherapists; active monitoring of her oxygen saturation levels and medication including Salbutamol to relieve her breathing difficulties and help clear any secretions. She was also monitored for signs of any chest infection and given antibiotics when needed. Throughout her time in hospital her NEWS score remained steady so there was no sudden deterioration in her condition. By 26 March, Mrs Stockley was transferred to the Princess Royal Hospital in Haywards Heath for further rehabilitation and to be closer to one of her sons address. It was noted that the amount of air reaching the side of her right lung was reduced and a chest XR was ordered. She continued to have chest physiotherapy, saline nebulisers and antibiotics. Between 1-3 April there was a period of stability as noted in the NEWS records and Mrs Stockley was using less pain relief. However, by 8 April, the breathing difficulties resurfaced and without oxygen her saturation levels dropped but rose again after receiving oxygen. A chest x-ray suggested a raised right hemidiaphragm and some fluid was collecting at the base of both lungs. A specialist respiratory review was conducted during the afternoon of 9 April and concern expressed that the hemidiaphragm may be paralysed. An ultrasound scan was recommended and new targets for maintaining oxygen saturation levels between 88- 92% were set to be monitored every 2 hours. Arterial blood gas tests were carried out followed by a further review by the critical care outreach team who did not make any changes to the respiratory registrar's plan. These were repeated again that evening by a junior doctor and he requested the nursing staff to carry out observations throughout the night. Mrs Stockley was monitored every 2 hours and at 6.35 a.m. her NEWS score was 4 but doubled to 8 by 7.20 due to a raised respiratory and heart rate. Nursing staff contacted the same junior doctor but he did not review Mrs Stockley on the ward. Later the same day her condition deteriorated rapidly and she descended into respiratory failure which required transfer to intensive care for eventual intubation on 10th April. An ultrasound confirmed consolidation and collapse of the right lower lobe with minimal diaphragmatic movement. Between the 10th April and her eventual death on 20th April efforts were made to wean down her ventilator setting and reduce her sedation to allow her to do more of her own breathing. This did not work as she become agitated and on one occasion tried to remove her tube. Further ventilation was discussed but eventually she was placed on an end of life pathway until she died on 20th April at 02.28. 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. On9Q April, Mrs Stockley's respiratory condition was clearly deteriorating necessitating critical care review who recommended careful and consistent observation of principally her oxygen saturation levels. The NEWS score was a vital tool to alert clinical staff to an acute change yet despite the fact the score went from 4 to 8, the junior doctor did not review the patient. | heard evidence from nursing staff that the doctor felt the patient may simply have been anxious. This suggests a potential training need for doctors and/or nurses. 2. Further, although the nurse quite rightly telephoned a doctor it was far from clear whether the right doctor had been contacted. The national NEWS forms were in use at the time of Mrs Stockley's death to record observations but the policy that governed their use was the 2012 MEWS Escalation Policy and the two policies were different. From evidence heard from both doctors and nurses, it suggests the need to revisit how the NEWS policy is applied locally especially around which doctor should be contacted when there is an acute change. 3. The nurse who had monitored Mrs Stockley throughout the night and contacted the junior doctor when the NEWS score spiked handed over to the day nurse shortly after her conversation with the doctor. From evidence heard at inquest, there may | still be reluctance for nursing staff to contact doctors at a more senior level if a junior doctor does not take appropriate action such as a patient review. 4. Finally, during the inquest | heard from an independent expert that some hospitals use an automated electronic NEWS system which may have avoided the difficulties encountered in Mrs Stockley’s case. 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 7 September 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: lam 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: 12™ August 2016 Pr GeBuwe eck Karen Harrold Assistant Coroner West Sussex
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.
Brighton and Sussex INHS| Our Ref: GF/MLS/C9/15/33/GF181/SF University Hospitals NHS Trust The Royal Sussex County Hospital Ms Karen Harrold, HM Assistant Coroner Eastern Road Coroner's Office, West Sussex Record Office Brighton Orchard Street BN2 5BE Chichester West Sussex Tel: 01273 696955 PO19 1DD Dear Ms Harrold The Late Jean Stockley, date of birth: 20 January 1931 NHS No: 416 747 3917 Thank you for your letter of 15 August 2016, and for drawing your concerns to my attention. As you may know, this Trust is always willing to review our practices, in order to identify improvements which can be made in the light of experience. Your report has been circulated to relevant senior staff within the Trust to ensure that learning is as wide as possible. Using the same numbering as in section 5 of your report, for ease of reference, | hope the following comments will help to reassure you about progress that has been made since April 2015: 1. | regret that the documentation arising from the nurse’s call to the doctor after the NEWS score had risen was so brief, and that neither the doctor nor the nurse concerned could recall this telephone conversation at all. The ward has since adopted a protocol known as SBAR (Situation / Background/ Assessment/ Recommendation), which includes documentation. This helps staff (especially nurses) to frame critical conversations raising concern about their patient, and has been shown to improve communication and patient safety. A special form is used to prepare for and record such telephone conversations, and is then placed in the patient's health records as a record of the call. | was disappointed to learn that on this occasion the doctor had apparently not visited the ward when he was notified of the sudden rise in Mrs Stockley’s NEWS score. 2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed. With our partner © brighton and sussex “2 medical school 3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. it is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from the advice received from the junior doctor first contacted. 4. The Trust is considering carefully the series of actions which will need to be taken to enable an electronic NEWS system to be introduced. The Trust provides clinical services in a wide range of buildings across several sites. As an essential preliminary step, WiFi cover is being extended to cover the whole Trust. It is anticipated that this will be in place in 2017, enabling the Trust to make further progress in automating observations. Thank you once again for raising your concerns with me. Finally, | would like to extend my sincere condolences to the family of Mrs Stockley on their sad loss. Yours sincerely Dr Gillian Fairfield Chief Executive
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