Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0177, written 10 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2016 |
|---|---|
| Reference | 2016-0177 |
| Deceased | Christine Street |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners CATHARINE PALMER LL.B (HONS) . KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHA W, BA(LA W)HONS 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. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr. Gillian Fairfield, Chief Executive, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton 2. P| Medico-Legal Manager, Brighton and Sussex University Hospital NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton CORONER tam 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 On 14" September 2015 | commenced an investigation into the death of Mrs. Christine Street. The investigation concluded at the end of the inquest on 29" April 2016. The conclusion of the inquest was NARRATIVE CONCLUSION. Following admission to hospital on 22" August 2015, Mrs. Christine Valerie STREET was diagnosed with an aggressive brain tumour. Her symptoms were disorientation, confusion and a generalised left-sided weakness affecting capacity to mobilise and leaving her prone to falling. This left her in need of continuous one-to-one care and assistance when mobilising. Due to her lack of mental capacity and attempts to leave the hospital, Mrs. STREET was subject to a Deprivation of Liberty Safeguarding Order. VERONICA HAMILTON-DEELEY, LL.B. THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) : KAREN HENDERSON, BSC,BM,MRCPLFRC. - GILVA D.J.TISSHA W, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Following a loud noise at approximately 5:30am on 11" September 2015, she was found lying unattended on the toilet floor following an unwitnessed fall. The resulting head injury was minor but had a traumatic impact and accelerated the pace of her deterioration and timing of her death : q + CIRCUMSTANCES OF THE DEATH See Record of Inquest 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) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11 September 2015 (was not completed). The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street's notes. (2) Mrs. Street was being specialled. She was on arm's length observations and had been since just after her biopsy on the 28" August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11" September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be speciailing her, it was clear that the handover to him on the 10 September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the g” September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8a West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11" she was appropriately managed. The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31" August 2015) was not adhered to by the HCA. The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31° August, there was absolutely no documentation at ail. This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy. 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 Telephone: Brighton ‘CATHARINE PALMER LL.B (HONS) Fax: Brighton KAREN HENDERSON, BSC,BM,MRCPLFRC. . GILVA D.J.TISSHAW, BA(LAW)HONS There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust's own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unfikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust. The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately. (3) From the 12" September 2015 the recording of doctor's visits, of nurses observations and the processes around the recognition of the dying patient were utterly flawed, unprofessional and unacceptable. | do not propose to rehearse all the things that went wrong since | am quite sure that there shouid now be a full investigation into what happened by the hospital. This is not the first Regulation 2 report that | have had to write recently (in the last few months) following Inquests and concerning the hospital's failure to recognise the dying patient and act appropriately and in accordance with their own and with national guidance. This is a matter which exercises everyone these days particularly following the discussion which arose following the Liverpool Care Pathway AND IT MUST be addressed by this hospital Trust. This abject failure did not, the Jury accepted from the evidence, affect the care that Mrs. Street was given following her fall and head injury. The lack of recognition and the lack of procedures did not affect her and therefore did not either cause or more than’ minimally contribute to her death, which is why this Regulation 28 Report is so important. These failings did however have a huge impact on her large and loving family who were denied all the support that they should have been given as set out in the End of Life Care Protocols for this Hospital Trust. 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 2" August 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. THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Telephone: Brighton] Fax: Brighton VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPLFRC.. GILVA D.LTISSHA W, BA(LAW)HONS 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Medical Director, Neurological Unit, Royal Sussex County Hospital, Brighton Secretary of State for Health, Department of Health Simon Stevens ~ Chief Executive NHS England National Patient Safety Agency Clinical Commissioning Group Peter Wilkinson — Director of Public Health | Chair of BSUH NHS Trust — Director for Clinical Quality and Primary Care ON Oa haw | have also sent it to:- 1. 2. 3. End of Life Care Facilitator 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. Date: 10 May 2016 SIGNED BY: 7 \ Vopornet lan Qe Veronica‘ HAMILTON-DEELEY Senior Coroner Brighton and Hove
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.
RECEIVED -2 AUG 20% Brighton and Sussex University Hospitals Your ref: Our Ret: memes The Royal Sussex County Hospital Miss V Hamilton-Deeley, HM Senior Coroner Eastern Road Coroner's Office, Woodvale agnor Lewes Road BRIGHTON vo BN2 3QB Dear Miss Hamilton-Deeley The Late Christine Street, date of birth 31.03.1944 NHS No: 418 862 7476 Thank you for your letter of 6 May 2016, and for drawing your concerns to the attention of the Chief Executive. ASB is currently away from the Trust, she has asked that | respond to you on her behalf. | am aware that the Chief Executive acknowledged that the care provided to Mrs Street was unacceptable, and indeed wrote to the family shortly after her arrival at the Trust early in April 2016, to apologise about this before the inquest took place. She and | both believe it is vital that the Trust staff really learn from experience when something has gone wrong. | am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialling’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding. A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills. It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. ,_Nevertheless, in her weekly messipevr@atinetaff, the Chie£Ey OFIQNIGN aNd SUSSEX mecical school reminded all staff of the scope for further improvement, as well as taking the opportunity to remind us all of the actions to be taken should someone fall. Following receipt of your letter, she has also used her weekly message to remind staff to make sure they are familiar with the Trust policy on observation of patients mentioned above, as well as to use the adult care pathway for people requiring one to one care, acting on the prompts contained within it and documenting these actions comprehensively and contemporaneously. Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient. Furthermore an audit has been carried out very recently of every patient being specialled. The findings are now being collated and action will be taken, including if necessary revision of the current policy, in the light of any learning points that emerge from this audit. In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records. Learning from these sad events is not limited to the Directorate of Neurosciences and Stroke Services. The Directorate Lead Nurse gave a formal presentation to her fellow senior nurses from across the whole Trust, after the inquest, to disseminate the lessons to be learned as widely as possible. Thank you once again for raising your concerns with the Trust. Yours sincerely = a3 ss
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