Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0066, written 22 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2016 |
|---|---|
| Reference | 2016-0066 |
| Deceased | Clifford Crofts |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Suzanne Rankin, Chief Executive Ashford and St Peter’s Hospital Trust
1
CORONER
I am Caroline Topping, Assistant Coroner for the coroner area of Surrey
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.
3
INVESTIGATION and INQUEST
4
On 15 October 2015 an investigation into the death of Clifford Irwin Crofts was
commenced, the investigation concluded at the end of the inquest on 12 February 2016.
The conclusion of the inquest was that Mr Crofts died as a result of 1a. Respiratory
failure, 1b. Lung collapse and acute bronchitis 1c Pleural effusions II Peritonitis due to
gastrostomy leakage and a-typical Parkinson’s disease.
He died at St Peter’s Hospital Chertsey on 10 October 2014 as a result of a respiratory
failure. He had a previous medical history of COPD and Parkinson’s disease and had
recently suffered from peritonitis following a gastrostomy leakage.
The conclusion as to death was natural causes.
CIRCUMSTANCES OF THE DEATH
Mr Crofts had been admitted to St Peter’s Hospital a number of times during 2014 as a
result of aspiration difficulties arising from Parkinson’s disease. Owing to difficulties in
providing Mr Crofts with sufficient nutrition and medication it became necessary to try to
insert a PEG feeder. That attempt failed. On Friday, 19 September 2014, a radiologically
inserted gastrostomy tube (RIG) was inserted. Following the insertion the consultant
radiologist filled in a post-operative care plan (no. 94) which is used by the trust. This
document went missing from the Mr Crofts’ notes. There was some advice recorded in
the medical notes from a dietician, it was not identical to the post-operative plan.
Feeding began through the RIG on 20 September 2014 at 15.45, with acute pain being
experienced after 20-30 minutes. The plan called for advice to be sought from a senior
medical adviser urgently and for a CT scan to be considered in such circumstances.
Attempts to escalate Mr Crofts’ care by the nursing staff were unsuccessful until 1.55 on
the 21 September 2014 when he was seen by an SHO. A chest x-ray was undertaken
but no CT scan. A further review by a junior doctor at 0800 took the matter no further. At
11.00 the surgical team was contacted but was unavailable. At 15.30 the surgical team
was busy in theatre, but advised a CT scan be obtained. This was not arranged until
20.30. Mr Crofts was not seen until 23.40 by the surgical team and underwent a
laparotomy and washout at 4.30am on 22 September 2014. He improved after the
surgery but thereafter his respiratory difficulties could not be resolved and he
deteriorated and died on 10 October 2014.
5
CORONER’S CONCERNS
RT4744
1
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths could 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) The Trust’s care plan no 94 RIG was not followed. The SI report dated the 20
August 2015 (page 19) recommends that relevant staff members are aware of and
understand the policies, guidance and supporting documentation which relate to the
care of patients who have undergone enterostomies. I was informed this
recommendation had not yet been put into effect.
(2) There were considerable difficulties in escalating Mr Crofts’ care on 20 and 21
September 2014. The SI report recommends that the process by which care is escalated
within and between disciplines needs to be reviewed and clarified to ensure that patients
receive timely attention. Again, I am not satisfied on the evidence I have heard that this
recommendation has been implemented.
(3)There were considerable difficulties obtaining a CT scan on Sunday, 21 September
2014. This was partly because it was not actioned at 16.00, when requested. After 17.00
on the weekend the request had to be made by a consultant to an outside provider
Medica who read the scans when no-one is available at the hospital. It appears that
junior doctors can now request CT scans and that a new arrangement is being put in
place to obtain urgent CT scans in cases of suspected peritonitis. The SI report
recommends that guidance relating to CT scanning on the trust intranet should be
reviewed to clarify the process for arranging investigations and be made available as
part of the induction process for junior doctors and on the ward areas, for other staff to
access. I was informed this has not yet been actioned.
(4)During the course of evidence it became clear that the delay in attempts to escalate
Mr Crofts’ care over the weekend was due in large part to staffing levels. Whilst I heard
that staffing levels at weekends have increased since 2014, it was not clear that the
number of doctors at all levels of seniority available at weekends is sufficient to provide
safe care to in patients at the hospital particularly at times when emergencies arise in A
and E.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I 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 18th April 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 following Interested Person,
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
22.2.2106 Caroline Topping
RT4744
2
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.
Ashford and St. Peter's Hospitals ES NHS Foundation Trust St Peter’s Hospital Guildford Road Chertsey 15/04/2016 Surrey KT16 OPZ Ms Caroline Topping HM Coroner's Court DX 119775, Chertsey 2 Station Approach Tel 01932 872000 Woking . Web www.ashfordstpeters.nhs.uk Surrey Text Relay prefix numbers with 18001 GU22 7AP Dear Ms Topping, RE: Mr Clifford Crofts Regulation 28 Report to Prevent Future Deaths Please find below my responses to your concerns raised following the inquest into the death of Mr Crofts; 1. The Trust’s care plan no 94 RIG was not followed. The Si report dated the 20 August 2015 (page 19) recommends that relevant staff members are aware of and understand the policies, guidance and supporting documentation which relate to the care of patients who have undergone enterostomies. | was informed this recommendation had not yet been put into effect. Several changes have been made to safeguard patients who have feeding enterostomies. e These procedures are not urgent and are no longer undertaken on Fridays (or at weekends). This enables the nutritional support Specialist Nurses to provide specific and directed training to ward areas each time one of these patients is present. e The RIG care plan is commenced in radiology when the device is inserted and accompanies the patient to the ward area. The care plan has full details of the management of these devices and the complications which may result from their insertion or use. e The Care plans detailing the use of enterostomies and their complications are available on the Trust intranet via any workstation in the organisation and will be present in any ward where such a patient is an inpatient. e A module has been produced for our on line training system for staff (Training Tracker) which covers many aspects of nutritional care including the use and complication of feeding enterostomies. Our junior doctors are signposted to this system and its contents during their induction program prior to commencing clinical duties at the Trust. Patients first « Personal responsibility « Passion for excellence = Pride in our team Ashford and St. Peter's Hospitals WHS RHS Foundation Trust 2. There were considerable difficulties in escalating Mr Croft’s care on 20 and 21 September 2014. The SI report recommends that the process by which care is escalated within and between specialties needs to be reviewed and clarified to ensure that patients receive timely attention. Again | am not satisfied on the evidence | have heard that this recommendation has been implemented. e Difficulties with inter-specialty referral of inpatients have been identified in several SI reports and a pilot scheme has been developed for use on labour ward which utilises a referral template based on SBAR principles. SBAR is a formal communication tool recommended by the NHS Institute for innovation and Improvement which consists of standardised prompt questions within four sections (Situation, Background, Assessment and Recommendation), to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively. This template requires the referring specialty to specify the level of response required (ie the grade of clinician to undertake the review) and the timescale for review. A formal process of escalation is described for occasions where the response to the referral is for any reason not adequate. If the pilot scheme is successful, use of the referral template will be rolled out across the organisation. . There were considerable difficulties obtaining a CT scan on Sunday, 21 September 2014. This was partly because it was not actioned at 16:00 when requested. After 17:00 on the weekend the request had to be made by a Consultant to an outside provider Medica who read the scans when no-one is available at the hospital. It appears that junior doctors can now request CT scans and that a new arrangement is being put in place to obtain urgent CT scans in cases of suspected peritonitis. The SI report recommends that guidance relating to CT scanning on the trust intranet should be reviewed to clarify the process for arranging investigations and be made available as part of the induction process for junior doctors and on the ward areas, for other staff to access. | was informed that this has not yet been actioned. e There is a revised guidance document available for doctors who request CT scanning out of hours (Mon — Fri 20:00 to 08:00 and Sat, Sun & Bank holidays 17:00 to 09:00). e Scans for patients on the following pathways no longer require a discussion with the Medica radiologist e CT Heads for head injury, stroke or possible subarachnoid haemorrhage. e Trauma (other than isolated head injury) o Quad CT for multiple injuries o Cervical spine CT as per NICE guidelines. e Acute abdomen pathway Patients first » Personal responsibility © Passion for excellence « Pride in ourteam Ashford and St. Peter's Hospitals NHS) NHS Foundation Trust e For other CT scans requested out of hours a discussion with the Medica radiologist is required but direct consultant involvement is no longer necessary (except for paediatric head scans). e The guidance is available both in full and abbreviated forms on the Trust intranet and junior doctors are signposted to the guidance as part of their induction process prior to commencing clinical duties. 4. During the course of evidence it became clear that the delay in attempts to escalate Mr Croft’s care over the weekend was due in large part to staffing levels. Whilst | heard that staffing levels at weekends have increased since 2014, it was not clear that the number of doctors at all levels of seniority available at weekends is sufficient to provide safe care to in patients at the hospital particularly at times when emergencies arise in A and E. e The Trust is committed to the provision of emergency care which does not vary with time of day or day of week, as described in the Keogh Standards. The timescale for compliance with the 10 Keogh Standards is the end of 2016/17 (financial year). e We have recently adjusted the medical junior doctor rotas such that there is an extra doctor on the emergency medical take from 16:00 to 23:00 every day. e In contrast to nursing practice, there is no guidance as to what constitutes ‘safe staffing’ for doctors. This is an issue we are trying to address at Ashford and St Peter’s and the Medical Director is leading a work-stream which is attempting to define, for each clinical area and each grade of doctor, the safe minimal level of medical staffing. It is likely the implementation of identified safe staffing levels for doctors will require the introduction of the new contracts for both junior doctors and consultants as at present there are significant restrictions on our ability to roster doctors to perform elective work within ‘premium time’ (19:00 to 07:00 weekdays and any time at weekends). Please do not hesitate to contact me if you require further details on any of these points. Yours sincerely, Suzanne Rankin, Chief Executive Ashford and St Peter’s Hospitals NHS Foundation Trust Patients first » Personal responsibility * Passion for excellence © Pride in ourteam
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