Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0296, written 18 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 | 18 Aug 2016 |
|---|---|
| Reference | 2016 – 0296 |
| Deceased | Diana Ritchie |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC. BMMRCPLFRC... - GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Brighton and Sussex University Hospitals NHS Trust 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 INVESTIGATION and INQUEST i On 9"" August 2016 | commenced an investigation into the death of Diana Maxine RITCHIE. The investigation concluded at the end of the inquest on 9" August 2016. The conclusion of the inquest was Narrative Conclusion. 14 CIRCUMSTANCES OF THE DEATH See Record of Inquest 15 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) Mrs Ritchie was recovering from major surgery and on her second day post L | operatively was suspected of having an Ileus. Overnight on the 5" and 6” VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 KAREN HENDERSON, BSC,BM,MRCPLFRC. - GILVA D.J.TISSHAW, BA(LAW)HONS March she deteriorated quite substantially and a doctor was called to see her in the early hours of the 6"" at that time there was no suspicion that she was suffering from a bronchopneumonia but the evidence at the Inquest indicated that this was the start of the that infection. The differential diagnoses at that stage were Pulmonary Embolis or the effects of Ileus. | (2) That there were missed opportunities to escalate Mrs Ritchie’s treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team. There were eight different NEWS scores taken between 06.30 on the 6" and 11.15 on the 6". On two of them the scoring was inaccurate (one was scored 2 points too high and the other was scored 2 points too low). One of them scored at 4 but the remainder scored at 5 and above. As! say, none of them resulted in a call to critical care outreach or to the ward SHO. (3) If care had been escalated there would have been at least 4.5 extra hours from the earliest NEWS chart for Mrs Ritchie to have been assessed by an : independent clinician who may well have taken different action to the action that | was taken to her. i If care had been escalated it may well have been that she may not have suffered the cardiac arrest which occurred around about 12.20 hrs on the 6". Itis possible that the outcome might have been different. (4) The other area of concern | have is that the observations were not taken more regularly during the night of the 5'/6"" March when it was clear that Mrs Ritchie’s | condition was deteriorating — it should not have needed any form of direction from the doctors attending for these observations to be taken more regularly. The Nurse in charge of the ward should have been informed and should have made a direction for the appropriate timing of these observations. (5) It was also suggested to me that the observations taken at 11 o’clock, 11.05, 11.10 and 11.15 were not in fact taken at those times but were taken later, after the first relatively short lived loss of consciousness which occurred at around 11.15. If this is correct then this is really an extremely worrying use of this assessment tool. (6) Finally this is not the first time | have had to write a Regulation 28 Report to this Trust which involves abuse of or failure to use NEWS properly at all. It is in my view necessary for there to be substantial and immediate training on proper use of NEWS throughout the Trust. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner THE CORONER’S OFFICE WOODVALE, LEWES ROAD for the City of Brighton & Hove oe B BRIGHTON s) a ex BN2 30B Assistant Coroners EAS Telephone: Brighton (01273) 292046 CATHARINE PALMER LL.B (HONS) aX hone Fax: Brighton (01273) 292047 KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LAW)HONS - | am told that there are electronic hand-held ‘smart’ pieces of equipment which | can be used to take and record NEWS and which then omit a warning signal if the NEWS is raised. This should be considered at this hospital. | understand that Worthing Hospital (recently rated excellent by the CQC) has this handheld equipment and uses it to good effect. 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. 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" November 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 . Clinical Quality Commission . Clinical Commissioning Group ~ Soline Jarram . Secretary of State for Health, Department of Health f . Simon Stevens — Chief Executive NHS England . National Patient Safety Agency HE — Medico Legal Services Manager OnkRwWNn- | have also sent it to:- aT Who may find it useful or of interest. 1 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. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPLFRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 9 Date: 18" August 2016 SIGNED\BY: Senior Coroner Bri
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 NHS) University Hospitals NHS Trust The Royal Sussex County Hospital 1 November 2016 Eastern Road Brighton BN2 SBE Miss V Hamilton-Deeley HM Senior Coroner Coroner's Office Woodvale Lewes Road BRIGHTON BN2 3QB Tel: 01273 696955 Dear Miss Hamilton-Deeley The Late Diana Ritchie, date of birth: 15 February 1933 Thank you for your report of 18 August 2016, and for drawing your concerns to my attention. | was very sorry to learn of the sad death of Mrs Ritchie. As you know, we are always willing to review our practices, in order to identify improvements which can be made in the light of experience. | appreciate that with hindsight, it is likely that Mrs Ritchie’s deterioration during the night of 5/6‘ March 2016 arose from the onset of broncho- pneumonia, although | am also aware that her clinical signs when she was examined at 03.45 were not such as to raise any suspicion of a chest infection. acknowledge and deeply regret (as | know do the staff who were directly involved in her care) that there is just a possibility that with earlier escalation for assessment by critical care team members, the sequence of events for Mrs Ritchie might perhaps have been different. | am aware that she was seen and thoroughly assessed by her consultant on the morning ward round on 6 March, who did not feel that such escalation was indicated at that time, let alone earlier that day. | recognise, as does the Trust’s interim Chief Nurse, that accurate completion and scoring of observations on the National Early Warning charts, and appropriate escalation, is very important. In the light of these events, considerable action has been taken on the ward concerned (in conjunction with their matron) to ensure that the individuals directly caring for Mrs Ritchie, as well as the rest of the ward team, are fully familiar with what is expected of them. They have reflected carefully on this, as well as attending specific additional training since these sad events to improve their knowledge and skills. The ward action plan is being presented to the monthly audit meeting for women’s services, as well as feedback being taken to the safety and quality meeting for wider learning. With our partner swe¢ Drighton and sussex medical schoo! Teaching on completion of the National Early Warning System (NEWS) and escalation of concerning scores is included on the nurse induction course which every new member of nursing staff is obliged to attend. in addition, the Trust’s Outreach team run teaching sessions on escalation of concerns arising from observations as part of the development programme for nurses, as well as running a monthly specialist training course for nurses which includes teaching on NEWS, In order to extend this learning more widely, | used the Spotlight on Safety, in my weekly message to all staff, to focus on NEWS, saying - among other things - “it is vital that NEWS scores are calculated correctly and acted on appropriately if we are to provide safe care for our patients” and providing a direct link to the Trust’s Patient Observation Policy. The Trust’s Patient Safety team sends a “Patients 1°” bulletin each month to all staff. This uses a fictionalized story to draw attention to things that may go wrong and sets out good practice. Since the death of Mrs Ritchie, such a bulletin has been circulated, which focused on the recognition and appropriate escalation of care for a deteriorating patient. The Trust has also established a specific working group entitled “the Deteriorating Patient Steering Group” to coordinate work across the Trust to improve recognition of, and response to, any patient whose condition is deteriorating. The Trust is considering carefully the series of actions which are essential before any electronic NEWS system can be introduced. The Trust provides clinical services in a wide range of buildings - some extremely old - 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. The Trust Senior Management Team has given support in principle to the introduction of an electronic NEWS system, and the detailed business case required for such an investment is actively being taken forward. Thank you once again for raising your concerns with me. Finally, please pass on my condolences on their sad loss to the family and friends of Mrs Ritchie. Yours sincerely Interim Chief Executive
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