Prevention of Future Deaths reports · 2016
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 report | 27 Apr 2016 |
|---|---|
| Reference | 2016-0181 |
| Deceased | Ernest Higgs |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Epsom and St Helier University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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
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.
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
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
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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