Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0420, written 24 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 | 24 Nov 2016 |
|---|---|
| Reference | 2016-0420 |
| Deceased | Beryl Farmer |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Sandwell and West Birmingham Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive, Sandwell and West Birmingham Hospitals NHS Trust
2. Family of the late Mrs Farmer.
3. Care Quality Commission-
CORONER:
I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country.
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 7 September 2016, I commenced an investigation into the death of the late Mrs
Beryl Farmer. The investigation concluded at the end of the inquest on 23 November
2016. The conclusion of the inquest was a short narrative conclusion of: Accidental
death contributed to by neglect. The cause of death was:
1a Subdural Haemorrhage
II Ischaemic Heart Disease, Hypertension, Left Ventricular Failure, Atrial Fibrillation,
Type 2 Diabetes Mellitus, Chronic Kidney Disease
4
CIRCUMSTANCES OF THE DEATH
1. Mrs Farmer was a 77 year old woman with a medical history including chronic
kidney disease, ischaemic heart disease, hypertension, diabetes, dextrocardia
and situs inversus. She was admitted to Sandwell Hospital on the 20 June 2016
after experiencing symptoms of loss of appetite, weight loss and nausea.
2. She was diagnosed with severe hypocalcaemia secondary to severe vitamin D
deficiency. She also had significant postural hypotension with a drop of
25mmHg on standing. She received intravenous calcium infusions for
treatment.
3. On the 23 June shortly after 6am she had a fall from her bed and sustained an
injury to her face and head. This resulted in bruising to her right eye area and
her forehead. No CT scan was performed at this stage because it was
concluded that her GCS was 15/15 and no evidence of vomiting, and her key
observations were normal.
4. She was later discharged on the 24 June 2016. No documentation for a falls
risk assessment was available or had been completed.
5.
In addition a decision had been taken to move her from a monitored area to a
de-monitored area prior to the fall without consultation with the medial team.
1
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6. There was also a failure to perform further neurosurgical observations after the
first set of observations before discharge.
7. At home, her condition declined and she developed headaches and was
readmitted back to Sandwell Hospital on the 1 July 2016. A CT scan was
performed on this occasion and a subdural haemorrhage diagnosed.
8. Advice from neurosurgeons was sought and she was managed conservatively.
She then effectively remained in Hospital and went on to develop seizures as a
result of the subdural haemorrhage and sadly died on the 30 August 2016.
5
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. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling
(moderate to high risk). There was no evidence that a falls risk assessment had
been completed.
2. Given the risks of falls, there was no clear justification for moving her from a
monitored bay to an unmonitored bay.
3. After the fall, only one set of neurological observations were performed before
her discharge.
4.
In addition no CT Head scan was performed despite evidence of significant
bruising to her face and head.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
1. You may wish to consider further training for all those involved in this incident in
respect of requirements for managing risks of falls.
2.
In addition you may consider it is prudent in light of this incident to review your
policy on performing CT head scans particularly for those patients where there
is evidence of bruising to the head area.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 20 January 2017. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons; Family and Care Quality Commission.
I am also under a duty to send the Chief Coroner a copy of your response.
2
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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
24 November 2016
Mr Zafar Siddique
Senior Coroner
Black Country Area
3
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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.
Trust Headquarters Health & Wellbeing Suite Sandwell Hospital Lyndon West Bromwich B71 4HJ Tel: 0121 507 4871 Fax: Direct email: Diary through: Sent via email 19th January 2017 Mr Z Siddique H.M. Coroner Black Country Coroner's Court Jack Judge House, Halesowen Street Oldbury West Midlands B69 2AJ Dear Mr Siddique Re: Regulation 28 Report – Beryl Farmer I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 23 November 2016, in respect of the late Mrs Beryl Farmer. I should extend again the condolences of the Trust to Mrs Farmer’s family, to whom I am copying my letter. We do not accept however that the omissions you cite directly contributed to Mrs Farmer’s death. I note that of particular concern to you was the lack of risk assessment for falls and the absence of sustained neurological observations following her fall which resulted in significant bruising. Equally you have raised concerns regarding our lack of policy on performing CT scans on patients who have sustained a head injury with obvious visible bruising. I share those concerns and have looked into the matter personally. I have also drawn this situation to the attention of my Board operating in public. There is no ambiguity here that we need to do better. We are acting to reduce a likelihood of recurrence. We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff through our Intranet web site. Face to face training time will reinforce this pathway in the months ahead. Additionally we will issue a Patient Safety Notice (an internal safety alert) reminding staff of the importance of neurological observations and the link being made between the management of inpatient falls with a head injury and the pathway. We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017. Of course, policies and standards are only functional within a culture which prizes them. As colleagues from NHS England and the CQC are aware, we are currently undertaking work across our medical wards to try and ensure standards are raised. This is based on multi professional team based working, and looking to create a safety culture which is grounded in continuous improvement. This includes, but is not limited to, changed accountabilities at local level, ward based quality improvement time, and monitored board rounds for clinicians to challenge each other’s practice. These culture changes take time but the next 12 weeks will see intensive work to try and make the right start. , Assistant Director of Governance, would be best placed to provide My colleague, advice to your office on the detail of our plans or indeed to provide such updates as are required on our progress this year. She can be reached on Yours sincerely, Toby Lewis Chief Executive cc Mrs Farmer’s family Care Quality Commission NHS England , Director of Governance Acting Chief Nurse , Medical Director 2 | P a g e
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