Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0265, written 22 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 | 22 Jul 2016 |
|---|---|
| Reference | 2016-0265 |
| Deceased | Stephen Bird |
| Coroner | Crispin Butler |
| Coroner area | Buckinghamshire |
| 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.
OO Ds ‘axe, ET MON, C.G.BUTLER SENIOR CORONER + BUCKINGHAMSHIRE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Executive Director BMI The Shelburne Hospital Queen Alexandra Road High Wycombe Bucks HP11 2TR 1 CORONER ! am CRISPIN GILES BUTLER, Senior Coroner for Buckinghamshire 2 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. http://www legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Awww. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 16" May 2016 | commenced an investigation into the death of Stephen John Bird, aged 51. The investigation concluded at the end of the inquest on 21" July 2016. The medical cause of death was recorded as:- ja Pulmonary Embolism 1b Deep Vein Thrombosis ic Recent Surgery for Achilles Tendon Injury The narrative conclusion recorded was as follows:- Mr Bird underwent surgery at the Shelburne Hospital on 6" May 2016. Prior to the procedure he had been assessed as being at a high risk of Venous Thromboembolism (VTE) and this was recorded in the medical notes. Mr Bird was re-assessed subsequently and considered to be a low risk of VTE. Pharmacological VTE prophylaxis was not prescribed. A mechanical VTE prophylaxis regime was prescribed. Mr Bird died at his home address during the afternoon of 11" May 2016. Mr Bird’s death resulted from a risk of the surgical procedure. 4 CIRCUMSTANCES OF THE DEATH Mr Bird had an elective operation on the 6" May 2016 at the Shelburne BMI hospital High Wycombe for an achilles tendon injury. The procedure appeared to go well and he was discharged the same day with Codeine as pain killers and thrombo embolus deterrent Coroner's Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ Tel: (01494) 475 505 Fax: (01494) 673 760 E Mail: coroners@buckscc.gov.uk SD, ey > ad Sr > Sy, er Hon C.G.BUTLER SENIOR CORONER + BUCKINGHAMSHIRE stockings. On the 11th May 2016 Mr Bird's partner left the house approximately 0800hrs. She spoke with Mr Bird at midday and all appeared normal. He was found at 1830hrs by the partner's daughter collapsed unresponsive on the floor next to his bed at his home address. Paramedics attended but Mr Bird was declared deceased at his home address. He was taken to Wexham Park Hospital where a post mortem examination was carried out and the described medical cause of death identified. Further investigations with the Shelburne revealed that Mr Bird was not prescribed anti-coagulation but was given an exercise regime upon discharge. The key facts established during the Inquest were recorded in a brief, neutral narrative conclusion. 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) The patient records, the documentation of consultations, clinical decisions, changes to previous assessment decisions and the discharge records were incomplete, inconsistent and/or conflicting and this was acknowledged during the Inquest hearing. (2) Evidence given regarding the investigation by the hospital into Mr Bird’s death and the preparation of a draft Significant Clinical Incident Investigation (SCII) Report (disclosed as part of the Inquest process) identified an assumption of facts within that draft report which conflicted with documentary records and this was acknowledged during the Inquest hearing. It was indicated during the hearing that the hospital places reliance upon SCIl reports as part of a learning process. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 16" September 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 Coroner’s Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 25) Tel: (01494) 475 505 Fax: (01494) 673 760 E Mail: coroners@buckscc.gov.uk | | | C.G.BUTLER SENIOR CORONER - BUCKINGHAMSHIRE | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- The Bird Family Consultant, The Shelburne Consultant Anaesthetist, The Shelburne HE Director of Nursing & Quality, The Shelburne | have also sent a copy of this report to the Group Executive Director, BMI Healthcare House, 3 Paris Gardens, Southwark, London SE1 8ND | 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 Dated 22 July wa Signature Senior Coroner for Buckinghamshire Tel: (01494) 475 505 Fax: (01494) 673 760 | IL i It Coroner’s Office, 29 Windsor End, Beaconsfield, Buckinghamshire. HP9 2JJ E Mail: coroners@buckscc.gov.uk
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 | BMI South Buckinghamshire Serious about health. Passionate about care. | Hospitals Private and Confidential Mr C.G.Butler Senior Coroner- Buckinghamshire 29 Windsor End Beaconsfield Buckinghamshire, HP9 2JJ 16" September 2016 Dear Mr Butler, Regulation 28 Report— Stephen John Bird | am writing in response to your Regulation 28 Report of 22 July 2016 following the Inquest of Mr Stephen John Bird. You have asked the Shelburne Hospital (“Hospital”) for a response to the matters of concern raised within the report and to detail the action/s and proposed action/s to be taken by the Hospital, along with the timetable for these actions. Please see our responses below. Concern 1 The patient records, the documentation of consultations, clinical decisions, changes to previous assessment and discharge records were incomplete, inconsistent and/or conflicting and this was acknowledged during the inquest hearing. It is accepted that the standard of record keeping was poor and not in accordance with the standards expected by BMI Healthcare (“BMI”). The following issues were identified: e The consultant surgeon’s documentation was poor. There were no contemporaneous records of consultations and clinical decisions made. e Mr Bird’s VTE risk assessment undertaken at pre-assessment was not updated on admission. e The World Health Organisation safer surgery checklist was incomplete. e Mr Bird’s pain score/status was not documented on return to the ward or on discharge. e It was documented by the physiotherapist that stairs were declined by Mr Bird but the reason for decline was not documented. e The discharge paperwork was inaccurate. The Chiltern Hospital The Shelburne Hospital The Paddocks Clinic London Road, Great Missenden Queen Alexandra Road, High Wycombe Aylesbury Road, Princes Risborough Buckinghamshire HP16 OEN Buckinghamshire HPI! 2TR Buckinghamshire HP27 OJS T: 01494 890 890 F: 01494 890 250 T: 01494 888 700 F: 01494 888 701 T: 01844 276 000 F: 01844 347 028 W: www.bmihealthcare.co.uk/chiltern W: www.bmihealthcare.co.uk/shelburne W: www.bmihealthcare.co.uk/paddocks BMI Healthcare Limited Registered in England Number 2164270, Registered office BMI Healthcare House, 3 Paris Garden, Southwark, London SEI 8ND. SPD326 e The discharge follow-up phone call was not undertaken. e Abbreviations used in the physiotherapy notes created confusion. In response to these concerns the following actions have been identified: 1. At the Hospital Medical Advisory Committee (MAC) meeting on 21 July 2016 the consultant record keeping was discussed. The committee took a serious stance on the standard of record keeping by consultants and it was agreed that there would be zero tolerance to non- compliance of GMC Good Medical Practice Guidelines on completion of medical records. Consultant medical records will be audited by the Director of Clinical Services on a monthly basis and non-compliance by any consultant may result in suspension of the consultant’s BMI practicing privileges. The MAC Chair and Executive Director wrote to the consultant body of both BMI Shelburne and BMI Chiltern Hospital accordingly on 25 August 2016. 2. Documentation training for staff at BMI Shelburne and BMI Chiltern Hospitals commenced on 15 August 2016 and is on-going on a monthly basis. 3. Corporate review of the use of abbreviations by physiotherapists is to be undertaken by BMI’s Group Clinical Services Director and the National Lead for Physiotherapy Services this month. In the meantime a list of abbreviations issued by The National Lead for Physiotherapy Services for outpatient documentation only is in use. 4. A monthly audit of discharge follow-up phone call documentation has been introduced and commenced on 1 August. 5. All Hospital staff to review the BMI Venous Thromboembolism (VTE) Prevention policy, which commenced 1 August. The Director of Clinical Services is collating signature sheets as evidence of compliance. Concern 2 Evidence given regarding the investigation by the hospital into Mr Bird’s death and the preparation of the draft Significant Clinical Incident investigation (SCII) Report (disclosed as part of the inquest process) identified an assumption of facts within that draft report which conflicted with documentary records and this was acknowledged during the inquest hearing. It was indicated during the hearing that the hospital places reliance upon SCII reports as part of a learning process. The investigation report used for the investigation into Mr Bird’s death and the inquest process was the BMI Signficiant Clinical Incident Investigation Report. However, the BMI Root Cause Analysis (“RCA”) report should have been used. Further, the report in places differed to the documented notes in the medical records. Please be advised that reports concerning the investigation of the death of an unexpected patient remain in draft format pending conclusion of the Inquest to ensure all issues identified at the Inquest can be addressed in the report. In response to these concerns the initial investigation report has been reviewed and a RCA has been completed. We enclose a copy of the finalised RCA. | would like to assure you that we have taken the matters of concern identified in your report extremely seriously. Progress with both completed and outstanding actions will be reviewed and monitored and learnings shared across the BMI Group. | trust the responses given have addressed your concerns and may | take this opportunity to again express the Hospital’s sincere condolences to Mr Bird’s family. Yours sincerely
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