Prevention of Future Deaths reports · 2016

Milly Zemmel

Regulation 28 report to prevent future deaths, reference 2016-0139, written 6 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Apr 2016
Reference2016-0139
DeceasedMilly Zemmel
CoronerNigel Meadows
Coroner areaManchester City
CategoryHospital Death (Clinical Procedures and medical management) related deaths
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:

e Professor Matthew Makin, Executive Medical Director, North
Manchester General Hospital — Pennine Acute Hospitals NHS
Trust

Copied for interest to:
e The family of the deceased

CORONER

| am Nigel Meadows, H.M. Senior Coroner for the area of Manchester City.

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.

INQUEST

On 3 March 2015 | commenced an investigation into the death of Milly
ZEMMEL, aged 89. The investigation concluded at the end of the inquest
on 29 March 2016.

The cause of death was found to be:
la Right upper lobe pneumonia
i Fractured neck of femur, chronic kidney failure
Recurrent confusional state

The conclusion of the inquest was Accidental Death contributed to by
neglect.

4 | CIRCUMSTANCES OF THE DEATH

The deceased, who was aged 89, and registered blind, lived in sheltered
accommodation.

She had the benefit of carers who visited her regularly as well as family
members. However, on 7 February 2015 she was feeling particularly
unwell and an ambulance was called. She was admitted into North
Manchester General Hospital (NMGH).

She was initially seen and assessed in the Accident and Emergency

Department. Following this she was admitted to Ward H3 where, despite
being blind, she was assessed as not being at risk of falls. This was later
acknowledged by NMGH to be totally incorrect and her care plan was not

appropriately completed nor was her risk of falls correctly assessed.

She suffered from chronic conditions, ischaemic heart disease, kidney
disease, anaemia, gout and diverticular disease. Her presenting
symptomology suggested that she may have suffered an injury to her
elbow in a fall but she did not report having had a fall.

She was treated with supportive therapy but over the next few days
suffered episodes of acute confusion and disorientation. She was
transferred to Ward E5 on 9 February and her risk of falls was
reassessed. She suffered further episodes of confusion and
disorientation and it was suspected that she was suffering from a urinary
tract infection. On 21 February 2015 the deceased suffered an
apparently witnessed fall at her bedside. Initial nursing assessment
detected no obvious injuries and she was assisted back to sit in her chair.
A request for medical review was made and initial neurological
observations were commenced. No clinician attended to review her until
she was seen on 25 February and this was not escalated appropriately by
the nurse in charge of the ward on 21 February and nor was it noted or
recognised when her care was handed over to a number of shifts
thereafter.

Between 21 February and 1 March 2015 it is recorded that the deceased
was repeatedly confused and agitated. At about 5am on 1 March 2015 it
is recorded that she was suffering an acute confusional episode and
requires one to one supervision. She appeared to be hallucinating and
had been in and out of bed constantly. Despite this no one to one
supervision was initiated and there was no evidence that her deteriorating
condition was handed over to the next shift starting at approximately
07.30am. She had previously been subject to a regime of two hourly
checks, however, that morning she was not checked and was not subject
to one to one supervision for several hours. At around 11.30am she was
found on the floor by her bed after having had an un-witnessed fall.

Subsequent investigations established that she had suffered a fracture of
her left femur. Clinically it was decided that she was not fit enough for
surgery and despite treatment her condition deteriorated and she died on
3 March 2015.

Following the death of the deceased NMGH initiated an investigation into
her fall on 1 March 2015 and produced a template report. It concluded:
“The patient has a poor standing balance, requiring assistance of one,
and was suffering from acute delerium with history of impaired vision.
Whilst the care plans and risk assessments were all in place there was a
failure to consider a low rise bed, tab alarm or patient watch”.

The deceased was in fact totally blind and did not have impaired vision. It
was recognised that after having a fall at her bedside on 21 February
2015 she had not been clinically reviewed until 25 February and this had
not been escalated or recognised by anyone. A number of action

eT! .
recommendations were made.

The internal hospital investigation did not fully and properly identify the
gross failure to provide the deceased with the basic medical care which
her condition obviously required on the moming of 1 March 2015. The
full particulars only became apparent when evidence was heard at the
inquest and the records were checked. The gravity of the failings in care
had not been properly identified.

Following the death of the deceased the Hospital Trust introduced a new
risk falls policy and initiated training for staff.

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:

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. The Trust’s own internal investigative procedures were
demonstrably inadequate because the internal hospital
investigation did not fully and property identify the gross failure to
provide the deceased with the basic medical care which her
condition obviously required on the morning of 1 March 2015. The
full particulars only became apparent when evidence was heard at
the inquest and the records were checked. The gravity of the
failings in care had not been properly identified.

2. There have been failures to assess and correctly apply the then
existing falls risk policy.

3. There was a failure to escalate the requirement for a clinical review
following her fall on 21 February 2015 and nor was this identified
at handovers on several occasions.

4. There was a gross failure to initiate appropriate one to one
supervision and observations for the deceased from the early
hours of the morning on 1 March 2015. In addition there was a
failure to ensure that important clinical information about the
deceased’s condition was handed over to the next shift. Nor did
the next shift nurse in charge ensure that the deceased’s records
were checked to find out what the up to date information on the
situation was. Consequently the deceased, who was suffering an_|

acute confusional state, and who was blind was left unsupervised
for several hours leading her to have a fall and suffer a serious
injury which caused or contributed to her death.

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.

In my opinion action should be taken to prevent future deaths and |
believe your organisation has the power to take such action.

1. The Trust should consider reviewing their own internal investigation
systems and ensure that they are transparent, thorough,
appropriately candid and up to date. Those involved in the
deceased's care and management or who have line management
responsibility should not form part of any investigative team.

2. Whilst the introduction of a new falls policy is commendable and to
be applauded, there was failure in nursing and clinical hand-over,
escalation and management which should not have been allowed
to occur. This was part of basic nursing and clinical management.
The Trust should consider reviewing the hand-over and escalation
policies and protocols so as to ensure a fail safe system.

7 | YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3 June 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

| have sent a copy of my report to the Chief Coroner and to Interested Persons. | have
also sent it to organisations who may find it useful or of interest.

| 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.

6 April 2016
Manchester City Area

Nigel Meadows HM Senior Coroner -

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 Pennine Acute Hospitals (PDF)
Pridein The Pennine Acute Hospitals NHS!

Pennine NHS Trust
If calling please ask for: Gill Harris, Chief Nurse Trust Headquarters
Delaunays Road
Crumpsall
Manchester
Telephone: ml
26 May 2016

Private and Confidential
Mr S Meadows

H M Senior Coroner

H M Coroner’s Court
Manchester Town Hall
Albert Square
Manchester

M8 5RB

Dear Mr Meadows,
Re: Inquest following the death of Mrs Milly Zemmel held on 29" March 2016

Please find the Trust’s response to the recent Regulation 28: Report to Prevent Future Deaths,
served on the Trust on 7 April 2016 following the Inquest into the death of Mrs Milly Zemmel.

The Trust response and action taken to address the concerns that you raised are detailed
below.

Background

Mrs Zemmel was transferred to Ward E5 on 9" February 2015. Ward E5 was a temporary ward
opened in response to increased demand due to seasonal pressures at the beginning of 2015.

1. The Trust should consider reviewing their own internal investigation systems and
ensure that they are transparent, thorough, appropriately candid and up to date.
Those involved in the deceased's care and management or who have line
management responsibility should not form part of any investigative team.

It was recognised early in 2015 that the Trust need to make improvements in how
investigations were conducted within the organisation. An external review of serious incident
investigations was commissioned by the former Chief Executive and following this review the
Trust instigated a number of actions:

e The Trust revised and launched a new policy and procedures for investigation called the
Incident Reporting and Investigation Policy, including the Serious Incident Framework
(EDQ008 V6.4) in June 2015. This has provided clearer guidance for managers
undertaking investigation. The policy provides clear guidance on the grading, level and
type of investigation required for all incidents including those for serious incidents.
These are now investigated by a team independent of the clinical area where the
incident occurred and involve senior clinical staff who have the expertise and knowledge
to undertake the investigations.

Pridein

. The Pennine Acute Hospitals NHS)
Pennine :

AHS.

¢ A two day programme of root cause analysis training was commissioned by an external
company specialising in root cause analysis (RCA) training and 103 staff, including
senior clinicians and managers, were trained during 2015/16. In addition the Trust
delivered training on Duty of Candour (being open) to ensure that patients and families
receive support and feedback when a serious incident investigation is commenced. An
internal programme of investigation training will continue throughout 2016/17 to ensure
that the quality and breadth of Trust investigations continues to improve.

¢ To accompany the RCA training programme the Clinical Governance team have also
developed an investigation toolkit that covers all aspects of investigations and advice on
preparing and writing investigation reports.

Please see Appendix 1 for the full Policy - Incident Reporting and Investigation Policy, including
the Serious Incident Framework

2. Whilst the introduction of a new falls policy is commendable and to be
applauded, there was failure in nursing and clinical hand-over, escalation and
management which should not have been allowed to occur. This was part of
basic nursing and clinical management. The Trust should consider reviewing
the hand-over and escalation policies and protocols so as to ensure a fail-safe
system.

The Trust has piloted and now introduced a ‘Safety Huddle’ at the commencement of each
ward and departmental shift which includes the discussion and handover of any recent
incidents, as well as safety issues relating to patients. This includes a prompt for discussion of
any patients who will require additional observation or enhanced supervision as part of their
care. This allows nursing staff to report on any unexpected and significant events involving
patients and helps them to proactively plan and agree how to resolve them. The policy is within
Appendix 2 - Safety Huddle document.

The Trust launched a policy for Clinical Communication and Handover in September 2015
which includes handover documentation templates with more robust information for recording
safety concerns such as a patient who may be at risk of falls information and a standard
framework for escalating concerns about a patient. The policy also includes the standard
required for doctor to doctor handovers including for patients who have been referred and who
need to be assessed. The policy has been disseminated across the clinical teams in the Trust
and the senior nursing team undertake quarterly audits to assess the quality and level of
compliance. This policy is within Appendix 3 - Clinical Communication and Handover Policy.

The introduction of the New Falls Policy and Enhanced Patient Observation Policy

The new Fallsafe Policy for the prevention and management of in-patient falls was introduced
in April 2016; this includes newly launched tools for assessment, care planning and a care
bundle. As part of the launch, training was included using the Fallsafe resources produced by
the Royal College of Physicians and is available to all staff.

The Trust has now employed two Specialist Practitioners for falls to further enhance and
develop the systems and processes for the education and training of staff. Part of their work will
be to develop the processes for patient risk assessment and for auditing the implementation
and effectiveness of the policy in clinical areas. The FallSafe Policy is in Appendix 4 and the
Fallsafe staff information booklet is within at Appendix 5.

The Enhanced Patient Observation Policy was also introduced in February 2016 to ensure
patient safety and to help provide the appropriate level of supervision and observation for adult
in-patients. This policy provides advice and support to staff on the different requirements and
needs of patients who require observation. This can be found in Appendix 6 - Enhanced Patient
Observation Policy.

Pridein. Quality-Deven The Pennine Acute Hospitals [i7ah
Pennine Sate HS Trust

Dissemination of Lessons Learned

Failure to act and escalate the lack of medical review will be included in the Lessons Learned
Bulletin within the Medical Division and disseminated to all wards and departments across the
division. The learning for nursing staff is to escalate to the medical team and in the first
instance to the registrar and then consultant or on call Consultant, with assistance if required,
from within the senior nursing site team or on call/ bleep holder out of hours to ensure that any
request for urgent review occurs. Staff will be required to use the communication handover
SBAR tool (situation, background, assessment and recommendation) to support any
communication. This is contained within the Clinical Communication and Handover Policy.

| sincerely hope that the above response addresses your concerns and provides you and Mrs
Zemmel's family with the assurance that we have addressed the learning following the inquest
and our own investigation. Should you require any further information then please do not
hesitate to contact me.

May | take this opportunity to again convey the Trust's sincere apologies and condolences to
the family of Mrs Zemmel.

Yours sincerely

ei —
|

Chief Nurse

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