Prevention of Future Deaths reports · 2016

David Hughes

Regulation 28 report to prevent future deaths, reference 2016-0040, written 9 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Feb 2016
Reference2016-0040
DeceasedDavid Hughes
CoronerCatherine Mason
Coroner areaLeicestershire City and South Leicestershire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedLeicestershire Partnership NHS 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:

Dr P Miller, Chief Executive
Leicestershire Partnership NHS Trust,
Riverside House,

Bridge Park Plaza,

Bridge Park Road,

Thurmaston,

Leicester.

LE4 8PQ

CORONER

| am Catherine Mason, senior coroner, for the coroner area of Leicester City and
Leicestershire South

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.

INVESTIGATION and INQUEST

On the 23” April 2014 1 commenced an investigation into the death of David Granville
Oswald Hughes.

Cause of death
ta Peritonitis
1b Perforated duodenal ulcer

CIRCUMSTANCES OF THE DEATH

Mr. Hughes was a patient at the Bradgate Unit, Glenfield Hospital, Leicester. He had
been admitted to the hospital on the 18” April 2014 after the police had found him
wandering the halls of a hotel and had classed him as vulnerable. Whilst at the hospital
Mr. Hughes refused to engage with staff and was placed on 15 minute observations that
were to check that he was safe and well. These observations do not include physical
observations such as blood pressure, pulse and respirations but they were to be
conducted by properly checking Mr. Hughes and engaging with him at each prescribed
interval. Mr. Hughes was to have physical observations taken as part of his admission
but he continued to refuse to have this taken and medical evidence is that he had the
capacity to make this decision, Mr. Hughes was found unresponsive lying on his
bedroom floor collapsed at approximately 02:00 hours on the 23” April 2014. It is clear
from the evidence that there were serious failings in his care in so far as he was not
observed in accordance with his medical needs. However, medical evidence is that
there were no physical signs that Mr. Hughes was unwell such that action could have
been taken to prevent his death. Therefore, while the recording of his observations fell
way short of an acceptable standard, this failure did not cause or contribute to his death

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. —

4. Level 2 observations were not conducted at the prescribed time intervals and
periods of up to two hours lapsed between observations that should have been
conducted every 15 minutes. When observations were conducted they were not
always carried out as per the protocol. Assurances have been given at previous
inquests that the performing and recording of these observations would be
monitored, audited and staff would be trained regarding the importance of such
observations. The same assurances were given at Mr. Hughes’ inquest. It
therefore appears that changes have not been made or if they have they are not
working. Alternatively, changes may occur in the short-term but they are not
being maintained and therefore the monitoring and auditing systems, if
implemented, appear not to be working.

2. Fluid balance charts were not properly completed. There was no uniformity as
to how or when staff would record fluid intake. Some staff would record fluid if
they gave Mr. Hughes a drink, Some would record if they witnessed Mr.
Hughes drink it. Therefore, the fluid balance charts were rendered meaningless

3. Patient bedrooms are not fitted with a call bell system. The staff rely on patients
being able to leave their bedroom and seek help or be able to shout loudly
enough to be heard. Clearly, a patient who is so unwell that they can do neither
would not be able to alert staff that assistance was required

4. The nursing staff who gave evidence were Registered Mental Health Nurses or
Health Care Support Workers. The evidence that they gave suggested they may
not appreciate the signs and symptoms of a physical problem / illness. One
nurse said that he would not. Although it is understood that discussions have
taken place regarding the recruitment of 5 Registered General Nurses to
supplement the 2 already in post at the Bradgate Unit and address this concern,
it is understood that recruitment has not yet occurred and no date for
commencement of recruitment could be given.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by the 5" April 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

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

cac
Department of Health

wv

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” February 2016

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)
Leicestershire Partnership NHS)

NHS Trust
Direct dial: 0116 2950821/07786 111055
Email: frank.lusk@leicspart.nhs.uk A University Teaching Trust
Our ref: DGH/REG28/0216 Corporate Affairs
R 170, Penn Lloyd buildin:
29 March 2016 eon ™ cout) Hall
Leicester
; : - LE3 8TB
By email to Leicester.coroner@leicester.gov.uk
Mrs C Mason Tel: 0116 295 1350
Senior Coroner - Fax: 0116 225 5233
Leicester City and South Leicestershire www. leicspart.nhs.uk

The Town Hall
Town Hall Square
Leicester LE1 9BG

Dear Mrs Mason
Re: David Granville Oswald Hughes

Further to your report dated 09 February 2016, in accordance with paragraph 7,
Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, | offer the following response.

We carried out a Serious Incident Investigation following Mr Hughes death and
reported the actions we have taken as a result of the findings at the inquest. We
have also considered the matters of concern that have arisen during the course of
the inquest of Mr David Hughes. Leicestershire Partnership NHS Trust takes these
matters very seriously and | hope that you and Mr Hughes’ family will be satisfied
that we have taken the appropriate measures to prevent such an occurrence
happening again.

The matters of concern you have raised are as follows:

1. Level 2 observations were not conducted at the prescribed time intervals and
periods of up to two hours lapsed between observations that should have
been conducted every 15 minutes. When observations were conducted they
were not always carried out as per the protocol. Assurances have been given
at previous inquests that the performing and recording of these observations
would be monitored, audited and staff would be trained regarding the
importance of such observations. The same assurances were given at Mr
Hughes’ inquest. It therefore appears that changes have not been made or if
they have they are not working. Alternatively changes may occur in the short-
term but they are not being maintained and therefore the monitoring and
auditing systems, if implemented, appear not to be working.

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

Service response

The poor practice demonstrated by staff regarding observations at the time of
the incident is unacceptable and is not tolerated. A new version of the Trust's
Therapeutic Observation Policy was implemented in 2015 with staff
competency based training in the practical application of the policy. The
policy is aimed at observing patients in relation to risk of harm, however does
include assessment of physical wellbeing. All staff who carry out therapeutic
observations are competency checked by a ward nurse or matron before they
are allowed to lead on a patient's observations. This is applicable for all ward
substantive and bank staff

Further Action

The nursing staff directly involved in this incident were subject to the Trust's
Performance and Conduct Policy. As a result, the registered nurse involved
has been dismissed and referred to the Nursing and Midwifery Council
(NMC). The NMC investigation is still ongoing. The Healthcare Support
Worker was also subject to disciplinary procedure and was also dismissed.

All missed observations should be reported through the incident reporting
system and are subsequently reviewed by the relevant ward matron.
Responsible clinical staff involved in late or missed observations are
interviewed and action taken where necessary.

The Therapeutic Observation Policy will be reviewed by 30 April 2016 to
consider how the completion of therapeutic observation for physical health
concerns should be included or if separate guidance is required.

. Fluid balance charts were not properly completed. There was no uniformity
as to how or when staff would record fluid intake. Some staff would record
fluid if they gave Mr Hughes a drink. Some would record if they witnessed Mr
Hughes drink it. Therefore, the fluid balance charts were rendered
meaningless.

Service Response

The fluid balance chart in use across the Bradgate Unit was devised with the
Dietetic service. There is also a Trust Nutrition and Hydration Policy
explaining the standard of assessment and monitoring of patients food and
fluid intake. However, the use of the fluid chart and the recording on the chart
is not consistent by all staff and the service acknowledges the need for urgent
improvement in this area.

Further Action
The lead Dietician for Adult Mental Health has been asked to review the fluid
chart and its relationship to the Trust Hospital Nutrition and Hydration Policy.

It is expected the review of the forms will be completed by the end of April
2016 and implementation will be supported by training to all clinical staff

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

3. Patient bedrooms are not fitted with a call bell system. The staff rely on
patients being able to leave their bedroom and seek help or be able to shout
loudly enough to be heard. Clearly, a patient who is so unwell that they can
do neither would not be able to alert staff that assistance was required.

Service Response

There are currently 6 rooms identified for patients with physical disabilities in
that have call bells in Mental Health Acute Inpatient Services. Traditional call
bell systems are not appropriate for Mental Health areas (due to the ligature
tisks they present), which means the Trust does not have call bells fitted to all
Mental Health bedroom areas. However, the service is currently completing a
review of appropriate options.

Further Action

The service will conduct an appraisal and feasibility study to facilitate
appropriate (individual patient) call-bell facilities by 31 July 2016. The
preferred options will be presented to the Service Finance and Performance
Committee by September 2016 for investment decision.

During the interim period, increased observations levels will be set for those
patients who present as physically unwell. The frequency of these
observations will be agreed within the multi-disciplinary team and adjusted as
required by clinical assessment. Bradgate Unit patients presenting with
physical disabilities or illness will be prioritised admission into our disabled or
call-bell equipped bedrooms.

4. The nursing staff who gave evidence were Registered Mental Health Nurses
or Health Care Support Workers. The evidence that they gave suggested
they may not appreciate the signs and symptoms of a physical problem
/illness. One nurse said that he would not. Although it is understood that
discussions have taken place regarding the recruitment of 5 Registered
General Nurses to supplement the 2 already in post at the Bradgate Unit and
address this concem, it is understood that recruitment has not yet occurred
and no date for commencement of recruitment could be given.

Service Response

Although mental health nurses do have training in basic physical healthcare
the service acknowledges the benefits to patients of integrating additional
General Nurses into each ward's multi-disciplinary team and it is the service's
commitment to facilitate this.

Further Action

Although the service has had two physical health lead nurses in post since
July 2015, the service acknowledges the practical limitations of a limited sized
team. The service has agreed to expand our general nurse team at the
Bradgate and has consequently completed a cycle of recruitment into new
posts. However, there were no applicants and a second cycle has
commenced with a closing date in March 2016. It is acknowledged that

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

nursing recruitment across all specialist areas is difficult at present and if
there are no applicants again the service will review this strategy and consider
other workforce diversity options.

We hope this reassures you that we have taken appropriate action in response to
your findings in respect of individual staff concerned and the systems and processes
supporting the Bradgate Unit's physical healthcare services to provide safe and
effective care in order to reduce the risk to our future patients.

ir Peter Miller
Chief Executive

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ROS/p,

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Chair: Cathy Ellis Chief Executive: Dr Peter Miller

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