Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0207, written 2 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2016 |
|---|---|
| Reference | 2016-0207 |
| Deceased | Clarice Hilton |
| Coroner | Rachael Griffin |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Boroughs Partnership 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of the 5 Borough Partnership NHS Foundation Trust, Hollins Park House, Hollins Lane, Winwick, Warrington, WA 2 8WA 1 | CORONER | I am Rachael Clare Griffin, Assistant Coroner, for the Coroner Area of Manchester West. 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 On the 2nd February 2016 I commenced an investigation into the death of Clarice Beverley Hilton, born on the 29" October 1936. The investigation concluded at the end of the Inquest on the 20" May 2016. The Medical Cause of Death was:- ia Bilateral Pulmonary Embolism 1b Deep Vein Thrombosis The conclusion of the inquest was that Clarice Beverley Hilton died as a consequence of naturally occurring disease where she was suffering from depression and anxiety and as a consequence she was less mobile, eating and drinking less which led to dehydration, refusing to take medication which included prescribed anticoagulation therapy, and refusing to allow medical staff to undertake physical observations upon her to determine whether she required transfer to the Medical Assessment Unit. CIRCUMSTANCES OF THE DEATH | On the 21st January 2016 the deceased, who suffered with depression and anxiety, and who was prescribed Rivaroxaban for Atrial Fibrillation, was admitted to the Cavendish Unit, The Avenue, Leigh Infirmary, Leigh under Section 2 of the Mental Health Act 1983 due to her refusing to eat, drink and take her prescribed medication. She was physically assessed on admission and her Modified Early Warning Score was zero. She continued to refuse to eat and take her medication and only drank minimal fluids. She also refused to allow the medical staff to undertake any observations to record her vital statistics after the evening of the 21st January. Her Modified Early Warning Score was not therefore further assessed. On the 23rd January 2016 there had been a deterioration in her physical health and she became unresponsive on the Unit. She was transferred to the Royal Albert Edward Infirmary, Wigan where she died that day. 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. During the inquest evidence was heard that:- i. The Cavendish Unit is a specialist psychiatric unit which provides assistance to patients with mental illness. The Unit does not provide medical treatment for physical illness. If a patient admitted to the Unit requires medical treatment, they will be transferred to the Medical Assessment Unit at the Royal Albert Edward Infirmary, Wigan which is part of the Wrightington, Wigan and Leigh NHS foundation Trust. ii. To assess a patient's physical health the nursing staff working on the Cavendish Unit undertake observations twice a day on each patient to ascertain if they require any medical treatment from a physical health point of view. These observations include measuring the patient's temperature, oxygen saturations, heart rate, blood pressure amongst other things. In carrying out these observations the nursing staff are able to calculate the patient’s Modified Early Warning Score (MEWS). In a patient who has no physical health problems this score will be zero, however if the measurements recorded fall outside the normal parameters, this will increase the MEWS and may trigger a physical medical assessment by a Doctor to establish if medical treatment is required. The level of the MEWS determines the level of assessment that is required. . In the care that was provided to Mrs Hilton these observations were not undertaken as she refused to allow the nursing staff to assess her after the first evening of her admission on the 2i* January. This resulted in her MEWS not being calculated for a period of over 24 hours prior to her death. During the course of the Inquest evidence was given that those working on the Cavendish Unit, and in fact all the other psychiatric units within the Trust, do not have access to guidance as to what action to take if a patient refuses to have their physical observations undertaken. It was felt that if there was such guidance this would be of benefit to the staff on the Unit to know what to do in such situations and when to seek an assessment by a Doctor. Evidence was given that such a policy could prevent the death of a patient in the future. 2. Ihave concerns with regard to the following:- i. That there is no policy or guidance in place within the psychiatric units governed by 5 Boroughs Partnership NHS Foundation Trust as to what action to take when a patient is refusing to allow the nursing staff to undertake observations to establish the condition of their physical health. I therefore request that consideration be given to establishing a policy within the Trust for the monitoring of the physical health of patients within the psychiatric unit in circumstances where a patient refuses to allow the nursing staff to calculate their MEWS, which would provide guidance to the nursing staff as to what action should be taken in these circumstances and when it is appropriate for a referral to be made for a Doctor to assess whether a patient requires transfer to the Medical Assessment Unit for further assessment and treatment. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" July 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. Po Mrs Hilton’s husband. I have also sent this report to the Chief Executive of the Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan Lane, Wigan, WN1 2NN and Wigan Borough Clinical Commissioning Group, Wigan Life Centre, College Avenue, Wigan, WN1 1NJ, who may find it useful or of interest. 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. Dated Signed 2™ June 2016 Rachael C Griffin
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.
5 Boroughs Partnership NHS Foundation Trust Our Ref: ma Your Ref: Chief Nurse & Executive Director of Operational . Clinical Services 5 Boroughs Partnership NHS Foundation Trust 28 July 2016 R Hollins Park House ” ECEive D Hollins Lane 82 AUG 209 Warrington Mrs R C Griffin WA2 8WA HM Assistant Coroner Greater Manchester West Tel: HM Coroner's Court Paderborn House Email: Civic Centre r Howell Croft North Bolton BL1 1JW Dear Mrs Griffin, Re: Clarice Beverley Hilton - Deceased Thank you for your letter dated 2 June 2016 with regards to your findings into the death of Clarice Beverley Hilton and the directions given under the Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | would like to advise you of the actions the Trust has taken both prior to the inquest and since receiving your letter. In response to your concern that there is no policy or guidance within our psychiatric units to inform staff of what actions to take when a patient is refusing to allow observations to establish the condition of their physical health, | can confirm the Trust have completed the following: We have implemented a full review of the Modified Early Warning Scores (MEWS) operational guidance that all in-patient teams work within. This review was led by the Trust Nurse Consultant for Physical Health and was supported by the Trust MEWS working group and Resuscitation Officer. This group had met prior to the inquest to make recommendations on actions staff should take when physical observations are refused and has met regularly since we received your concerns. We have changed our MEWS guidance to contain instruction for staff on assessing those who refuse to engage with MEWS monitoring. Hq . A Better View... of mind & body Chairman _ 3 WY: ky Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA . — Switchboard: 01925 664000 Pisa Revised guidance now includes conducting a general assessment using the A(airway) B (breathing) C (circulation) D (disability) E (exposure) approach taught to all front line clinical staff as a part of all Basic and Intermediate life support courses. The revised guidance also contains specific assessment of respirations and level of consciousness using AVPU (Alert, Voice, Pain, and Unresponsive) and skin pallor which are observational that can be completed through direct visual observation. There is also a more specific instruction regarding escalation to the nurse in charge and doctor when the patient is refusing MEWS. We have reviewed the MEWS recording chart so that these can be recorded. At present our revised guidance is in draft form, once this guidance is ratified this will be issued to all of our In-patient Teams and we will provide support and training to front line staff where necessary to ensure successful roll out. If | can be of any further assistance or you require further information about the steps we have taken, please do not hesitate to contact me. Yours sincerely, Chief Nurse & Executive Director of Operation Clinical Services A Better View... of mind & body Chief Executive: Mr. Simon J. Barber st Bee, a Chairman $ W: < Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA ra e Switchboard: 01925 664000 Cis pen
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