Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0391, written 1 Nov 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Nov 2016 |
|---|---|
| Reference | 2016-0391 |
| Deceased | Trevor Hunking |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS 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.
ANDREW JAMES COX Assistant Coroner for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Health Education England Blenheim House Leeds LS1 4PL CORONER lam ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon 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://www. legislation.qov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 24 June 2015 | commenced an investigation into the death of Trevor Paul Hunking, The investigation concluded at the end of the inquest on 26 October 2016. The conclusion of the inquest was that Mr Hunking died from complications of a necessary surgical procedure. CIRCUMSTANCES OF THE DEATH In July 2003, Mr Hunking suffered a myocardial infarction. After tests, he was diagnosed with diffuse coronary artery disease which was managed medically. In 2008, following an admission with chest pain he was additionally diagnosed with moderate aortic stenosis. A consultant directed that Mr Hunking have annual surveillance but this did not happen and he was lost to follow-up at this point. By 2015 Mr Hunking had developed severe aortic stenosis. He was referred for aortic valve replacement and coronary artery bypass grafting, with surgery planned for 21 June 2015. On 17 May 2015 he was admitted to Royal Cornwall Hospitals Trust with an acute deterioration. He was managed as an in-patient. On 22 May he was accepted for in-patient transfer into Plymouth Hospitals NHS Trust with a target of treatment being provided in the next 7-10 days. Mr Hunking's transfer had not happened by 11 June 2015. On that date following the personal intervention of his cardiologist his in-patient transfer was expedited and he was admitted to Plymouth Hospitals NHS Trust at approximately 21:00. Mr Hunking underwent unremarkable surgery the next day but sadly did not recover. He died in Plymouth Hospitals NHS Trust on 16 June 2015. Evidence was heard at the Inquest of the steps that have been taken since the death of Mr Hunking to address some of the pressures on the Cardiology and Cardiothoracic resources within the Royal Cornwall Hospital, Truro and Plymouth Hospitals NHS Trust in Plymouth. The evidence that was heard (7 i S27 Lead for Cardiothoracic Surgery in Plymouth Hospitals NHS Trust as well a: Medical Director, was that the current constraints on the service relate to the provision of qualified Cardiac Intensive Care Unit Specialist Nurses. In short, there are insufficient adequately trained Nurses available. 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax The Inquest heard that the problem is particularly acute away from London. The capital is able to attract more qualified staff because of the easier transport connections it enjoys with Europe from where, | was told, some of the Nursing specialists originate. In turn, this has led to Plymouth Medical Staff undertaking procedures in London so that patients can have the necessary cardiac intensive care specialist nursing treatment they require. | heard from NHS England at the Wee and he felt that it would be sensible to draw the consequences of the lack of specialist cardiac intensive care nursing staff to your attention. He indicated that you would be well placed to answer what steps were being taken to address the current shortage in the necessary staff. 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) A shortage of Cardiac Intensive Care Unit Specialist Nurses to deal with patients post- operatively. ACTION SHOULD BE TAKEN ae. 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 28 December 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 and to the following Interested Persons who are the Family, the Royal Cornwall Hospital Trust and Plymouth Hospitals NHS Trust. (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. Assistant Corone Plymouth Torbay and South Devon 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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.
NHS Health Education England Private Office 1st Floor Blenheim House Mr Andrew James Cox Duncombe Street Assistant Coroner for Plymouth Torbay and South Devon Leeds LS1 4PL Her Majesty's Coroner for the County of Devon 1 Derriford Park Derriford Business Park ee aed Plymouth PL6 5QZ 2 December 2016 Dear Mr Cox Thank you for your letter dated 2 November regarding the inquest touching the death of Trevor Paul Hunking. Since its establishment in 2013, Health Education Engiand has been working to support an increase in the overall general nursing supply. Nurses often go on to train as specialists and it is employers who are responsible for this. In cases where this does happen, although it is the employer's responsibility, HEE is always happy to support them to develop appropriate training. The particular specialty you have identified here is one of those cases. Ongoing workforce supply and retention of the specific specialist cardiac intensive care unit role remains the responsibility of the employer. As such, | have copied in Danny Mortimer, Chief Executive, NHS Employers an iii Medical Director, NHS Improvement to further address the matters of concern. Yours sincerely 2 a fF Cr Z a © £ RECEIVED 5, My, Professor lan Cumming OBE i 5 DES 7° Chief Executive Hq , CORONER'S OFFICE a Developing people for health and healthcare *, NHS Employers 2 Brewery Wharf Kendell Street Leeds LS10 1JR Tel 0113 306 3000 Fax 0113 306 3001 enquiries@nhsemployers.org www.nhsemployers.org Mr A J Cox Assistant Coroner: Plymouth, Torbay and South Devon 1, Derriford Park Plymouth PL6 5QZ 22 December 2016 Dear Mr Cox Mr Trevor Hunking: Regulation 28 report | write further to the Regulation 28 report issued to Health Education England (HEE) following the inquest into the death of Mr Hunking. | of HEE proposed to you that my organisation might be able to assist in addressing the issues identified relating to the availability of cardiac specialist nurses, and | write to that effect. The present organisational arrangements for the NHS in England are complex but | thought it would be useful to summarise the respective roles of the NHS organisations referenced in your regulation 28 report and a reply: e NHS England has responsibility for specifying and procuring (commissioning) specialist (‘tertiary’) services such as cardiac surgery from Trusts and Foundation Trusts e Health Education England acts on behalf of the Department of Health to ensure availability of education at undergraduate and postgraduate level for the NHS e¢ NHS Improvement is effectively the service regulator for Trusts and FTs who provide NHS services in England e NHS Employers represents NHS organisations in relation to workforce matters, leading work on their behalf. All four of these organisations hold therefore different responsibilities for supporting the work undertaken by a Trust such as Plymouth Hospitals NHS Trust. In Mr Hunking's case you identified a shortage of specialist nursing staff as a key concern, and | am able to identify two ways in which NHS Employers is helping address this issue. Firstly we are working to ensure that all Trusts and Foundation Trusts are able to access international labour markets. We led a campaign last year for nurses to be placed on the shortage occupation list, which improves the ability of the NHS to recruit nurses from outside the EEA. As you will see from the table below, the NHS employs a range of nursing staff from many different parts of the world. Whilst it is the case that a greater proportion of these international colleagues are to be found in London and the South East the numbers employed within the NHS in the South West are comparable to other parts of the country. HCHS Nurses & Health Visitors nationality by HEE Region, September 2015 UK EU Asta Africa other = Total EstMdbnds fy East wadlands 73,791 $95 767 S61) 10): 28.234 catottnjnd RTS) | caso tnd nista 2778 24s 741713 354 ron, suey Sus [TSP | ca suey sumax 10200 1901 5395957 204 nieve es SEONG 7%) under vornwet (947) 286 140) 1529 a gos tat: tnd set fas 254 1688 1207 03 a8 ott (ET rer o5 foil ) <a North West [[s3 MESA S ieee eet) He North West 50.021 1,663 1,643 493130 55,794. ee ey TS | nanesvoty sm7 ass a5) 573 a8 5H vcd: TT ex vatans a ‘Yorkshire & the Humber [EEL I Yorkshire & the Humber 31480 721 853 498 67 36,503 0% 10% 20% 30% 40% 50% GOR 70% 50% 90% 100% mUK @EU wAsia » Africa mOther Since June our work has increasingly focused on the longer term implications for migration policy resulting from the decision to leave the European Union. Secondly we are working with employers in the NHS to ensure that they do everything in their power to retain the staff that they do employ, wherever those staff may have come from originally. This programme assists NHS Trusts and FTs in sharing good practice to assist retention of staff. This includes work on flexibility of development and working patterns for staff as well as education and other initiatives. | have asked that this programme specifically identify whether there are particular actions that might be taken in relation to the retention of cardiac specialist nurses. Thank you for making me aware of the circumstances surrounding Mr Hunking’s death. | hope that | have been able to give you information which assists in the responses to the regulation 28 report you have issued. Yours sincerely (’ Daniel Mortimer Chief Executive NHS Employers 23 December 2016 Mr Andrew James Cox Assistant Coroner for Plymouth Torbay and South Devon Her Majesty’s Coroner for the County of Devon NHS) Improvement Medical Directorate NHS Improvement Wellington House 133 - 135 Waterloo Road London SE1 8UG T. 020 3747 0000 E: nhsi enquiries@nhs.net W. improvement nhs. uk 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Dear Mr Cox Re: Inquest touching the death of Trevor Paul HUNKING | write further to the Regulation 28 report issued to Health Education England (HEE) following the Inquest into the sad death of Mr Hunking. | Chief Executive of HEE referred your letter to me and | have also seen the response from Danny Mortimer, Chief Executive of NHS Employers. in his response, Mr Mortimer explained the respective responsibilities of the national NHS organisations referenced in your report, which are complex but important background to this issue. | understand from discussions with Plymouth Hospitals NHS Trust that they have taken significant steps locally to maximise their ability to recruit and retain specialist cardiac intensive care nurses, and have a range of local internal accredited training and competency programmes in place. We have worked directly with Plymouth Hospitals since your letter to understand the systems and processes in place and provide assurance on the issues raised. We recognise that nationally intensive care nurses are in short supply, but as outlined above Plymouth have done a great deal to address this. The Cardiac ICU has 10 funded ICU beds. They are supported by a further 6 cardiac level 2 beds. Currently they have a total of 6.6 vacant posts (9%), of which the majority are at band 5, and have an active recruitment programme. They operate a bank system and agency staff to support any shortfalls to maintain activity. Nationally, NHS Improvement is working with HEE to help address the concerns you raise regarding the availability of cardiac specialist nurses in a number of ways. Firstly, we are working in collaboration with both HEE and NHS England to review the wider national supply issues of Registered Nurses, and the longstanding impact this has had on recruitment and retention of qualified, specialist, cardiac, general and neuro intensive care nurses. We are currently reviewing the NHS operational! plans including workforce for this year and into next to ensure that system demand is deliverable with safe and sustainable workforce models. This work is aligned with NHS England whom also have an important role in supporting the system on workforce such as nursing staff. NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams. There are other opportunities to work in collaboration with HEE to support the training, development and retention of specialist critical care nurses. They require further development but could include: e Ensuring that continuing professional development (CPD) budgets are protected or enhanced to enable providers to fully access Higher Education Institution specialist courses, in numbers that will enable the workforce to grow, rather than stand still. The impact of the reduction in CPD budgets has had a direct impact on the number of staff trusts can support through these essential specialist courses. e An opportunity to ensure that all Higher Education Institutions offer local accreditation of internal specialist programmes. e An opportunity to undertake an early evaluation of the potential benefit of nursing associates within the critical care environment, with specific competency assessments as a mechanism to support level 2/3 Registered Nurse care. Retention of all staff is important and alongside NHS England and NHS employers we have a program of work on retention, in areas such as staff wellness and experience, sickness and absence management. These programs promote values in the NHS that support staff to deliver care. The opportunities outlined above require further development in collaboration with HEE, and NHS Improvement remains committed to working in partnership to explore and develop these opportunities. Thank you for bringing to my attention the circumstances surrounding Mr Hunking’s death. | hope that the information | have provided regarding how we are responding to the concerns you raise is useful. Yours sincerely (ut, to — a Executive Medical Director NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the Nationa! Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.
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