Prevention of Future Deaths reports · 2016

Ernest Higgs

Regulation 28 report to prevent future deaths, reference 2016-0181, written 27 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Apr 2016
Reference2016-0181
DeceasedErnest Higgs
CoronerCaroline Topping
Coroner areaSurrey
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedEpsom and St Helier University Hospitals NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published3

The report

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: 

Daniel Elkeles – Chief Executive  
Epsom and St Helier University Hospitals NHS Trust 
St Helier Hospital  
Wrythe Lane   
Carshalton 
Surrey 
SM5 1AA  

Keith Ward – Chief Executive BMA 
Basement Office 
78 Golborne Road  
London  
W10 5PS   

 – Clinical Chair Surrey Downs CCG 

Surrey Downs CCG 
Cedar Court  
Guildford Road 
Leatherhead  
Surrey 
KT22 9AE 

Mike Parish – Chief Executive Care UK  
29 Great Guildford Street 
London 
SE1 0ES 

Practice Manager/ Senior Partner   
Linden House Surgery  
Ashlea Medical Practice  
30 Upper Fairfeld Road  
Leatherhead  
Surrey  
KT22 7HH 

RTdoc/478-2015/Reg28/07-04-2016 

 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 1 

CORONER 

I am Caroline Topping, HM 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 2nd February 2015 an investigation was commenced into the death of Ernest Higgs, 
an inquest was then opened on the 24th June 2015 which concluded at the end of the 
inquest on 7th April 2016. The conclusion of the inquest was that Mr Higgs died as a 
result of 1a. Aspiration Pneumonia 1b. Dysphagia II. Parkinson’s Disease and Dementia.

He died at Epsom General Hospital on the 20th January 2015 as a result of aspiration 
pneumonia.  

The conclusion as to death was natural causes.  

CIRCUMSTANCES OF THE DEATH 
Mr Higgs was a resident at Milner House a nursing home in Leatherhead. He had been 
resident there since September 2014 when he was discharged from Epsom General 
Hospital. He had had a prolonged stay in hospital having initially been admitted following 
a fall but went on to develop UTIs, mild-moderate, dysphagia, Parkinson’s disease,  
recurrent aspirational pneumonias, acute renal impairment, advanced small vessel 
ischaemic disease and hospital acquired pneumonias. In the course of this hospital 
admission he was fitted with a PEG feeder.  
On discharge his swallow had improved and he was no longer fed through the PEG 
feeder though his nutrition was supplemented with fortesip administered via the PEG. 
On the 15th January 2015 Mr Higgs was seen by a GP at Milner House following a 
decline in his health. She diagnosed aspiration pneumonia and prescribed antibiotics. 
Her advice to the home was not recorded in the multi-disciplinary held by the home. 
There was confusion over whether the GP told the home to make Mr Higgs nil by mouth 
that day. That advice was said to have been given by phone to an administrator at the 
home.  It was not possible to make a finding about whether that advice was given owing 
to the lack of accurate records at the home but also the fact that no confirmation of the 
advice was sent by fax or email.  
Blood tests were also requested by the GP over the phone. There was a delay at the 
home in obtaining the written request and sample bottles from the surgery. As these 
weren’t obtained until after 3pm on a Friday the home delayed taking the bloods until the 
following Monday. No message was sent to the GP’s surgery to inform her of that delay. 
The results of the blood tests were in part required to inform a decision as to whether Mr 
Higgs should be hospitalised.  An issue arose as to whether it would have been possible 
for the home to access OOH pathology. There was conflicting evidence which it was not 
possible to resolve about what provision was available at Epsom Hospital to process 
community blood tests outside the normal opening hours of the pathology laboratory. If 
such a service existed the home was unaware of it and subsequent enquiries following 
an SI report had not clarified the issue.  
Mr Higgs was admitted to hospital on the 19th January 2015 when his condition 
deteriorated and died from aspiration pneumonia the following day.  

RTdoc/478-2015/Reg28/07-04-2016 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 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)  It was clear from the evidence that confusion arose over what advice had been 
given by the GP on the 15th January 2015. No record was made in the multi-
disciplinary notes by the GP of her attendance at Milner House. Care UK the 
parent company of Milner House offered to liaise with their local surgeries to 
ensure the records were made by visiting GPs. However it appears that the 
BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient 
Care” advises against GPs filling in multi-disciplinary notes. There was no clarity 
about whose responsibility it was to fill in the notes.  

(2)  Advice given by the GP over the telephone to make Mr Higgs “nil by mouth” was 
not recorded and no confirmation of that advice in writing was sent by email. 
There did not appear to be a safe system in place to ensure telephone advice 
was accurately sent and received. 

(3)  There was conflicting evidence from Care UK and Epsom hospital about OOH 
provision at the hospital pathology laboratory for community care providers 
resulting in a significant delay to a diagnostic blood test being undertaken. 

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 24th 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 

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

 Milner House Nursing Home. 

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 

      27th April 2016                             Caroline Topping 

RTdoc/478-2015/Reg28/07-04-2016

Responses

3 responses 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 Epsom and St Helier University Hospital NHS Trust (PDF)
Epsom and St Helier NAS:

University Hospitals
, NHS Trust

Ms Caroline Topping

Assistant Coroner Chief Executive’s Office

HM Coroner’s Court St Helier Hospital
Station Approach Wrythe Lane
Woking Carshalton
Surrey Surrey SM5 1AA
GU22 7AP ¥

Tl as

Web: www.epsom-sthelier.nhs.uk

9 June 2016

Dear Ms Topping

Mr Ernest Higgs (Deceased)
Response to Regulation 28 Report to Prevent Future Deaths

This letter comprises the formal response of Epsom and St. Helier University Hospitals NHS Trust (“the
Trust”) to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 27 April 2016
(“the Report”), made subsequent to the inquest into the death of Ernest Higgs, which was opened on 24
June 2015 and concluded on 7 April 2016. The Trust would like to again express our deepest sympathy

and condolences towards the family.

Background

Mr Higgs was an eighty- four year old man who suffered with mild - moderate dysphagia, Parkinson’s
disease, recurrent aspiration pneumonias, acute renal impairment and advanced smail vessel ischaemic
disease. Mr Higgs had been a resident at Milner House, (a nursing home in Leatherhead) since

September 2014.

On Thursday 15 January 2015 Mr Higgs was seen by a GP at Milner House who diagnosed aspiration
pneumonia and prescribed antibiotics and requested that he undergo blood tests. We understand from
the Inquest report that the sample bottles and the written consent for the blood test was obtained by
Milner House on Friday 16 January 2015 but that the blood samples were not taken until Monday 19

January 2015.

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000

Chairman Laurence Newman | Chief Executive Danie! Eikeles

On Monday 19 January 2015, before the blood tests were processed Mr Higgs’ condition deteriorated
and he was admitted to Epsom Hospital where he was treated for likely aspiration pneumonia with IV

antibiotics.
Mr Higgs died at 22:10 on 20 January 2015 on the Buckley Ward of Epsom Hospital.

The Inquest concluded that Mr Higgs died of natural causes as a result of aspiration pneumonia.

The Trust involvement in the inquest was limited to the fact that Mr Higgs died at Epsom Hospital. The

Trust was not deemed to be an interested party at the inquest but (Foundation Doctor, who
no longer works at the Trust) as the Doctor who signed Mr Higgs’ death certificate, was asked to attend.

T

he Preventing Future Deaths Report

The Report raises the following concerns:

1. It was clear from the evidence that confusion arose over what advice had been given by the GP on
the 15" January 2015. No record was made in the multi-disciplinary notes by the GP of her
attendance at Milner House. Care UK, the parent company of Milner House offered to liaise with
their local surgeries to ensure the records were made by visiting GPs. However, it appears that the
BMA advice to GP’s; ‘Quality First Managing Workload to Deliver Safer Patient Care’ advises
against GP’s filling in multi-disciplinary notes. There was no clarity about whose responsibility it

was to fill in the notes.

2. Advice given by the GP over the telephone to make Mr Higgs ‘nil by mouth’ was not recorded and
no confirmation of that advice was sent by email. There did not appear to be a safe system in

place to ensure telephone advice was accurately sent and received.

3. There was conflicting evidence from Care UK and Epsom Hospital about out of hours provision at
the hospital pathology laboratory for community care providers resulting in a significant delay to a
diagnostic blood test being undertaken.

Trust response:

The Trust is unable to comment on the first and second concerns raised except to note that whilst Mr
Higgs was at Epsom Hospital, on 20 January 2015, wes approached by one of Mr Higgs’
relatives who had concerns that despite Mr Higgs’ GP having recently instructed Milner House that Mr
Higgs should be nil by mouth and fed by PEG tube they had seen Mr Higgs with half chewed food in his
mouth. The following day Dr Wolrich raised a posthumous safeguarding alert in light of this.

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2608 | Main Switchboard 020 8296 2000
Chairman Laurence Newman | Chief Executive Daniel Elkeles

In relation to the Coroner’s third concern the Trust confirms that there is twenty four hour access to the
Trust’s pathology department, seven days a week and that the staff at Milner House would have been
able to access the out of hours pathology department at Epsom Hospital either via drop off in A and E or
by contacting the biochemist on call at any time between 14 and 19 January 2015. The blood results
would have been processed within a matter of hours of them being delivered and the results would have
been given to whoever was listed as the contact on the request slip which must be provided when the

bloods are left with the pathology department.

Whilst all GPs should be aware of the twenty four hour access to the Trust’s pathology department,
seven days a week, as a reminder, we are including the following statement within the newsletter sent
to the GPs within the Trust’s catchment area, due to be sent out later this month.

URGENT ACCESS TO PATHOLOGY OUT-OF-HOURS
Following the recent death of a patient admitted to Epsom Hospital, we wish to remind all GPs
with elderly patients, particularly those in care homes, that there is twenty four hour access to

the Trust’s pathology department, seven days a week.

On call staff (both medical and technical) can be contacted via the Trust switchboard to
arrange analysis. When urgent processing is required, samples should be marked as urgent and
dropped off either directly to the lab or out of hours via A and E who will arrange to deliver
them to Pathology. In addition to being sent to a patient’s GP, the results will also be given by

phone to whoever is listed as the contact on the request form.

We will also be sending a letter to each of our three local CCGs requesting that this information is passed

on to all registered care homes in their area.
| hope that this letter is of assistance.

Yours sincerely,

cc: | of Legal Services)

Mr Daniel Elkeles
Chief Executive
Epsom and St. Helier University Hospitals NHS Trust

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000
Chairman Laurence Newman | Chief Executive Daniel Elkeles
Response from Surrey Downs Clinical Commissioning Group (PDF)
NHS)

Surrey Downs
Clinical Commissioning Group

Improving
care
together \\

across Surrey Downs

Cedar Court

Guildford Road

Leatherhead

Private and confidential KT22 Sat

Te:

Richard Travers

HM Coroner for Surrey www.surreydownsccg.nhs.uk
HM Coroner’s Court

Station Approach

Woking 16 June 2016

Surrey GU22 7AP

Dear Mr Travers

Re: Mr Ernest HIGGS (Deceased)
Regulation 28 Report to Prevent Future Deaths

Thank you for your letter with regards the Regulation 28 Report for Mr Ernest Higgs; |
was sorry to read about the circumstances of his death and would like to extend my
condolences to his family.

| have reviewed your ‘matters of concern’ and noted items 1 and 2 are of particular
relevance in relation to the delivery of primary care. It should be noted that nursing
homes have private contractual arrangements with general practitioners, often known as
a ‘retainer’ and responsibility for contracting and commissioning of primary care is
currently held by NHS England.

At NHS Surrey Downs Clinical Commissioning Group (CCG) we have been concerned
with the general quality of care provision within local nursing and residential homes,
recent evidence from the Care Quality Commission would reinforce this view with a
number of nursing and residential homes being rated as either ‘inadequate’ or ‘requires
improvement’.

The key actions we are taking are detailed below: _

1. Our Quality Committee have undertaken an in-depth analysis of the issues relating
to nursing and residential care home quality, this was supported by the Care Quality
Commission, Surrey Care Association, Healthwatch Surrey, Surrey County Council
and NHS safeguarding specialists. The outputs of this in-depth analysis will lead to
changes in the way we commission and assure quality of services.

Interim Chief Officer: Ralph McCormack Clinical Chair: Dr Claire Fuller

2. Our Quality Team are working collaboratively with Surrey County Council and local
safeguarding leads to quality assure nursing and residential home providers and
support those in difficulty where care concerns arise.

3. We are at the final stages of developing a nursing home Primary Care Standard
(PCS), the PCS is a proactive health assessment and intervention by a general
practitioner at least twice per year for every nursing home resident. | will also ensure
that the requirement to clearly document and evidence instructions by a general
practitioner is also included.

4. We are recruiting a specialist dietician who will act as a central resource for local
nursing and residential homes, particularly for those residents who require specialist
nutrition through enteral or parenteral feeding regimes, as was the case with Mr
Higgs.

5. NHS Surrey Downs CCG leads the Continuing Healthcare (CHC) function on behalf
of all CCGs in Surrey, as a ‘spot’ commissioner | have asked the CHC team to raise
concerns should they find poor documentation either from the nursing/residential
home and/or poorly documented communication between general practitioner and
care home staff.

6. | have asked Surrey Care Association to communicate with its members the
importance of contemporaneous documentation, care home and sub contracted staff
registered with a professional regulator such as the Nursing and Midwifery Council or
General Medical Council have a professional obligation to ensure documentation is
accurate and contemporaneous.

| hope this letter provides you with assurance that we are taking this Regulation 28
Report to Prevent Future Deaths seriously and | would be happy to provide further
details should you require.

Yours sincerely

MAC .

Clinical Chair
Cc | Chief Nurse — Surrey Downs CCG
Head of CHC - Surrey Downs CCG

Deputy Director of Commissioning ~ Surrey Downs CCG

Director of Commissioning - NHS England

Interim Chief Officer: Ralph McCormack Clinical Chair: Dr Claire Fuller
Response from The Ashlea Medical Practice (PDF)
The AshLea Medical Practice
| MA MB BCHIR FRCGP DRCOG | ts—iOS BM BS MRCP(UK) DRCOG DFFP

MB BCh DRCOG DFFP | MB ChB, MRCP(UK), MRCGP, PGDip
MB BS DRCOG MRCGP Cardiology, MRCP(London)
/BSc MB ChB DRCOG DCH MRCGP PGDipENT PGCertMedEd
BSc MB BCh (SA) DRCOG MRCGP

MB.BS DRCOG MRCGP
i, MBChB, MRCP, MRCGP
MRCGP, MBChB

Gilbert House Linden House

GILBERT HOUSE SURGERY LINDEN HOUSE SURGERY
39 Woodfield Lane 30 Upper Fairfield Road
Ashtead Leatherhead

Surrey Surrey

KT21 2B KT22 7HH
Tel No: Tel No: as

30/6/16

Dear Ms.Topping :
ref Ernest Higgs section 28 response
Thank you for asking us a practice to respond to your concerns raised regarding Mr

E.H, We have had a number of discussions around this case including discussion as a
significant event.

In response to your concerns raised

1) Confusion over multi-disciplinary notes: We feel we need to await clarity from
the BMA on their position regarding writing in the multi- disciplinary notes
before committing to a stance.

It is currently the practice view that it should be the responsibility of the
nurses attending with the doctor to be writing contemporaneous notes of the
interaction. We are happy to clarify any issues regarding instructions at the
time of the visit however if the advice of the BMA differs from this we will
consider a policy to address this. We have discussed this with the nursing home
in question and they are in agreement that staff will be responsible for writing
contemporaneous notes while we are in attendance.

2) Around advice given over the telephone to nursing homes in general : We have
drafted a practice policy to address this issue. As far as we are aware it is
recognised practice that, when taking advice over the phone, nurses are |
advised to have the advice ratified by another nurse present. We are happy to
follow any complex instructions up with written advice (see attached)

3) In response to the issue over the delay in blood taking : Having had sight of the
response from Epsom Hospital this issue appears to have been resolved with
an action plan and we will ensure local nursing homes covered by the practice
are aware of 24 hour pathology cover.

We are obviously as a practice happy to work collaboratively with any nursing homes
we attend to in order to ensure communication is safe and effective within the
parameters advised to us by the BMA.

We will be auditing our responses to nursing home phone requests 6 months after
implementation to ensure there is sensible use of discretion in faxing information:

If there are any outstanding issues which you feel we need to address please do not
hesitate to contact the practice.

Pe. behalf of Ashlea medical practice.

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