Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0186, written 13 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 | 13 May 2016 |
|---|---|
| Reference | 2016-0186 |
| Deceased | Geoffrey Ellis |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) —- REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mrs Ann Barnes, Chief Executive Officer, Stockport NHS Foundation Trust, Stepping Hili Hospitai, Poplar Grove, Hazei Grove, Stockport CORONER Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South. w 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. INVESTIGATION and INQUEST On 14" September 2015 an investigation was commenced into the death of Geoffrey Ellis who died while an in-patient at Stepping Hill Hospital on 8th September 2015. The investigation conciuded with an Inquest heid on 12" January 2016 and 24" April 2016. The conclusion of the Inquest was: Misadventure contributed to by neglect Medical cause of death la Aspiration pneumonia b Vomiting secondary to Pseudo-Obstruction of Smail Bowel c Recent Laparoscopic Nephroureterectomy for Kidney Tumour and Chronic Peritoneal Adhesions ll Coronary Artery Atheroma, Hypertension CIRCUMSTANCES OF THE DEATH On 3 September 2015 Geoffrey Ellis was admitted to the Urology Department, Stepping Hill Hospital the Consultant Care off Consultant Urologist. Geoffrey Ellis was to undergo a left side laparoscopic nephro-uterectomy, removal of kidney and ureter. The operation was carried out on 37 September 2015 and to all intents was uneventful and a success, albeit that it was necessary to complete the operation by means of open laparotomy. Geoffrey Ellis was admitted to Ward C6 that evening. i] found | that a failure to exam Geoffrey Ellis’ abdomen and to detect distension, on and from 6" September 2015 and to treat hiccups possibly present for 24 hours but in any event present from the morning of 7 September until the late evening contributed either in combination or singularly, to Geoffrey Ellis’ death on the morning of 8” September 2015. CORONER'S CONCERNS During the course of the evidence it was discovered that nursing records and other Clinical documents were_not being written up adequately or at all. 1) A staff — | advised me that she did not refer to the Patient Monitoring Chart, kept at the foot of the patient’s bed at any time during her night shifts caring for Geoffrey, on 6/7" and 7/8" September. Neither to note the “—e iiniial and information, nor to record her own observations. 2) hand written entries in the clinical records were barely legible. The Inquest was adjourned on 12” January 2016 because when giving his evidence, was unable to read the entries made b' As a consequence of the illegibility of the entry by BE timea at 02:00 on 7" September, where she apparently notes, among other things, “bowels opened” (for the avoidance of doubt it — evidence that the note reads bowels opened) and of her failure to complete the PNC it is clear that on the Ward Round at 09:00 there was a misapprehension that Geoffrey Ellis had still not opened his bowels for the 4 days following surgery. | fully appreciate the lack of any adverse outcome in consequence on this occasion as Geoffrey Ellis should therefore have been managed accordingly, on the basis that he had not. It does surprise me that these issues, 1. have not been identified or raised by those working alongside 2. have not been identifi upon by those managing 3. were not picked up by| when carrying out a review of the records on preparing a statement for the inquest. In the circumstances | am concerned that may not be alone in failing to complete documents such as the Patient Monitoring Chart and/or creating illegibie or difficult to read clinical records. 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. — Illegible clinical records and/or a failure to complete important documents creates a serious risk of a breakdown in communication and misinformation within a patient’s care pathway. ACTION SHOULD BE TAKEN In my opinion action should be taken to develop a system, and to ensure its operation, to monitor clinical records and to identify and eradicate illegible record keeping and to identify and eradicate failures to complete important clinical records. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8" July 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner. | have also sent it to a. daughter of Geoffrey Ellis. | 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. 13.05.2016 Mr A Bridgman Assistant Coroner
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.
Stockport NHS) NHS Foundation Trust Our ref. Your ref. AB/HC/02191-2015 Oak House Stepping Hill Hospital Coroner's Court Poplar Grove Mount Tabor OCKpo Mottram Street SK2 7JE Stockport ; Telephone: 0161 483 1010 SK1 3PA Fax: 0161 487 3341 Direct line: 0161 419 5444 E-mail: & August 2016 Dear Mr Bridgman, Re: Geoffrey ELLIS (Deceased) Thank you for your letter, of 19 July 2016, concerning the inquest of the above named patient. As always, | am grateful to you for highlighting your concerns on the Regulation 28 ‘Report to prevent future deaths’ and for providing me with an opportunity to respond. Your concerns are as follows: 1) Ilegible clinical records and / or a failure to complete important documents, creates a serious risk of a breakdown in communication and misinformation within a patients’ care pathway. The Trust is currently in the process of installing an electronic patient record system (EPR); this is a computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper and electronic records, information will be available to them online in one place. We already use a variety of electronic systems to help staff look after our patients but the EPR will bring all this information about our patients together into one system for better and safer care. The Trust's electronic patient record system is being supplied by InterSystems, a global software company and the system is called ‘TrakCare’. InterSystems supply EPR systems to 463 hospitals in 25 countries worldwide. This system will improve patient safety and outcomes by standardising pathways underpinned by best practice, resulting in an informed workforce supported by comprehensive patient information at their fingertips. It will remove issues relating to the illegibility of written records and will also assist with the completion of important documents, as the system will employ a ‘force function’, meaning the record cannot be left incomplete. The roll out for the system will be completed in 2017. In the meantime we will continue to endeavour to improve written records and communication by undertaking monthly ‘live’ spot audits, of 30 records per audit, relating to inpatients on our wards. | hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if you have a her questions regarding this matter. Your Health. Our Priority.
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