Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0255, written 15 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2016 |
|---|---|
| Reference | 2016-0255 |
| Deceased | Margaret Gleeson |
| Coroner | Simon Jones |
| Coroner area | Manchester (West) |
| 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.
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: i. Mr Andrew Foster, Chief Executive, Wrightington Wigan & Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN CORONER I am Simon DA Jones, HM Assistant Coroner, for the Coroner Area of Manchester West 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. INVESTIGATION and INQUEST On the 8" October 2016 I commenced an investigation into the death of Margaret Mary Gleeson, a 70 year old lady born on the 5” May 1945. The investigation concluded at the end of the Inquest on the 22™ June 2016. The conclusion of the Inquest was “a rare complication of surgery for incisional hernia repair”. 4 | CIRCUMSTANCES OF THE DEATH The circumstances I found were: Margaret Mary Gleeson underwent an elective incisional hernia repair at the Royal Albert Edward Infirmary, Wigan on the 2nd October 2015, and during the operation sustained a tear to her mesentery, which is a rare complication of this surgery. On her return to the ward, her condition deteriorated and she developed sepsis, although this was not diagnosed until 2344hours on the 3rd October 2015. Following a CT scan which revealed extensive gas at the operation site she was returned to theatre at 0420 hours on the 4th October 2015 where she suffered a cardiac arrest on being anaesthetised. She was resuscitated and underwent an operation to resect the ischaemic bowel, but did not recover from the operation and died on the 4th October 2015 at 1900hours. |_| 7 6 | ACTION SHOULD BE TAKEN is proposed. 8 | COPIES and PUBLICATION CORONER’ N N 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. At the weekend the on call team had to do the job of 4 teams and that it was not possible to provide patients with the care they deserve. In thos circumstances, I consider that staffing levels should be reviewed. 2. The scoring of the MEWS tool on the medical charts had been done inaccurately, and the use of the MEWS tools did not appear to be clearly understood. It would appear that refresher training would assist In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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 9" September 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. EE eich Day, Solicitors for the family, Leigh Day Central Park, Northampton Road, Manchester, M40 5BP 2. The Right Hon Jeremy Hunt MP, Secretary of State for Heath, Department of Health, House of Commons, London, SW1A OAA 3. National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU 4. Care Quality Commission, Citygate, Gallowgate, Newcastle upon Tyne, NEi 4PA 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 15/07/2016
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.
J Wrightington, Wigan and Leigh INHS' NHS Foundation Trust | Chief Executive’s Office 8 September 2016 Trust Headquarters Royal Albert Edward Infirmary Simon D A Jones Wigan Lane HM Assistant Coroner Wigan Manchester West WN1 2NN HM Coroner's Office Paderborn House 2 Bolton BL1 10Y Dear Mr Jones Regulation 28 Response: Margaret Mary Gleeson (Deceased) Thank you for your Regulation 28 Report dated 15 July 2016. | understand that an inquest relating to the death of Mrs Margaret Gleeson concluded on 22 June 2016. | have been fully advised of the circumstances relating to Mrs Gleeson’s death and having read your report, | am grateful to you for bringing these concerns to my attention. Since the conclusion of the inquest Wrightington, Wigan and Leigh NHS Foundation Trust (“the Trust”) has been working to ensure lessons have been learnt from the events surrounding Mrs Gleeson’s death. | would like to take the opportunity to advise you of the actions already undertaken by the Trust and the proposed action to be taken in the near future. The review has addressed the following: 1. At the weekend the on call team had to do the job of 4 teams and that it was not possible to provide patients with the care they deserve. In the circumstances | consider that staffing levels should be reviewed. 2. The scoring of the MEWS tool on the medical charts had been done in accurately, and the use of the MEWS tool did not appear to be clearly understood. It would appear that refresher training would assist. The information below forms the Trust’s response in relation to our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013. Staffing Levels During the inquest evidence was heard that at weekends the surgical on call team were extremely busy which led to patients, on occasions, not always receiving the standard of treatment they should expect. The Directorate of General Surgery recognised the variation in patient care that existed between weekends and weekdays, and action has been taken accordingly. Please find enclosed a copy of the updated Action Plan in respect of the Trust’s Investigation Report into Mrs Gleeson’s death. Within that Action Plan you will note that the Surgical Division has now allocated a middle grade surgeon to undertake a 4 hour ward round for elective patients during weekends. This means that a middle grade clinician (such as a clinical fellow or surgical registrar) wilt PC ot Mo, A ? s % RS Chief Executive: Andrew Foster CBE 3 Ye ‘Ss ~ Cy spy your hospitals, your health, our priority now perform additional duties at weekends to check on patients who have undergone elective surgery. These middle grades will review the patients and report any concerns to their on-call Consultant. These changes have been made to ensure that the surgical rota for doctors is robust, and also to ensure that these patients receive a daily senior review. By making these changes elective surgical patients, such as Mrs Gleeson, are guaranteed to be seen by more experienced clinicians at weekends, thereby allowing junior doctors more time to undertake their other duties. To ensure there are sufficient clinicians to cover the additional ward rounds, the Trust is in the process of recruiting 2 clinical fellows. One appointment has already been made, and it is hopeful the second appointment will be filled in the upcoming weeks. The changes brought about by the additional weekend working is being monitored through the Trust’s Surgical Clinical Cabinet. The Cabinet is chaired by the Trust’s Acting Medical Director and is attended by senior representatives of the Surgical Division responsible for implementing these changes. MEWS Tool In addition to the above, it was evident at inquest that staff did not appear to understand how the MEWS chart should be scored, and additional training for nursing staff would be required. Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the teaching sessions heid to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care. Firstly, with regards to training of the MEWS tool this has been led by the Trust's Critical Care Outreach Lead, | through the QUEST programme. This programme trains nursing staff on the use of the MEWS Tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board. In addition to this, the Trust’s Director of Nursing, has established since the inquest, and is currently chair of, a dedicated Task and Finish Group to oversee the use of the MEWS Tool. The Group meets on a monthly basis to discuss the audit findings and to monitor compliance and accuracy of scoring. Secondly, extensive training programmes have also been held in recognising and responding appropriately to early signs of deterioration in patients, including sepsis, which was relevant in Mrs Gleeson’s case. This training has been led by the Trust’s dedicated Sepsis Specialist Nurse, Ms gam, through attendance at the Trust’s Sepsis Study Day. Evidence of staff attendance at this programme is contained within the enclosed Action Plan, and arrangements are in place to make this training mandatory for all nursing staff. | has also conducted a number of Sepsis ‘Drop-in’ sessions specifically for nursing staff on Swinley Ward where Mrs Gleeson was being cared for. These sessions have focused on sepsis recognition, understanding the sepsis screening tool and sepsis management. In addition to the above, the Trust also has in place the Acute lilness Management (AIMS) course that focuses on the recognition of the acutely unwell deteriorating patient, and how they should be managed. Training on sepsis is also contained within this course. Management of sepsis is audited on a monthly basis and the results are contained within the attached Sepsis Dashboards. has confirmed that these audits show improvements in sepsis screening, and also with the use of the Sepsis Six pathway within the Trust's A&E Department. Continued Monitoring The above actions will be monitored via the Trust’s Quality and Safety Committee which is chaired by a Non-Executive Director and attended by several members of the Executive team, including the Director of Nursing. Every month updates will be provided to the Committee on the actions listed above. | hope the above response is testament to how serious the Trust has dealt with events surrounding Mrs Gleeson’s death. The welfare of our patients is paramount and we will continue to ensure lessons are learnt. If you have any comments or suggestions in relation to the proposed actions above, | would be only too pleased to hear from you Yours sincerely An Andrew Foster CBE Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.