Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0456, written 15 Dec 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 Dec 2016 |
|---|---|
| Reference | 2016-0456 |
| Deceased | Jean McHale |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire and Luton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South Essex Partnership University 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.
Thomas R Osborne Senior Coroner for Bedfordshire and Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Pauline Philip The Chief Executive Luton & Dunstable Hospital Lewsey Road Luton LU4 0DZ | Ms Sally Morris The Chief Executive South Essex Partnership University NHS Foundation Trust (SEPT) Trust Head Office The Lodge Runwell Chase | Wickford Essex. SS11 7XX i CORONER ' , Lam Thomas R Osborne, Senior Coroner for Bedfordshire and Luton ' 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:/Avww. legislation .gov.uk/ukpga/2009/25/schedule/5/paragraph/7 / http:/Avww.legislation.gov.uk/uksi/2013/1 629/part/7/made INVESTIGATION and INQUEST | On 19 August 2016 | commenced an Investigation into the death of Jean | Marjorie McHALE aged 88 years . The Investigation concluded at the end of | the Inquest on 13 December 2016. The conclusion of the inquest was a) | Narrative that she had died from Sepsis from infected pressure ulcers. i | CIRCUMSTANCES OF THE DEATH | The deceased was admitted to the Luton & Dunstable Hospital on 9 July 2016 | t i i i Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | Fax 0300-300-8267 following confusion, fever and generally unwell. She had 2 large pressure sores (Grade 4) present on the sacral region. After thorough discussion with microbiology she underwent multiple antibiotic therapy for 5 weeks: her condition unfortunately failed to improve. Her Daughter stated that her mother was discharged from Hospital in April 2016 with Grade 2 Pressure Sores and arranged for nurses to visit. The deceased was seen by the Community Nurses and Carers on a daily basis. CORONER’S CONCERNS | During the course of the inquest the evidence revealed matters giving rise to concern. In that the number of tissue viability nurses both in the hospital and in the community is limited. 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) That if pressure ulcers are not treated appropriately then the elderly in the community will suffer, develop Osteomyelitis leading to Sepsis and death. (2) That there are not enough Tissue Viability Nurses working in the community or in the hospital to meet the needs of the patients (3) An urgent review is necessary. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Chief Executive have the power to take such action. | Your response must contain details of action taken or proposed to be taken, | proposed. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 February 2017. |, the coroner, may extend the period. setting out the timetable for action. Otherwise you must explain why no action is COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Senior Coroner, The Court House. Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | Fax 300-300-8267 | 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. aa THOMAS R OSBORNE Senior Coroner Bedfordshire and Luton Senior Coroner, The Court House. Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tel 0300-300-6559 | Fax 0300-300-8267
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.
Local Services, Local Solutions SM/SB/04 30 January 2017 Trust Head Office The Lodge Mr Tom Osborme LL.B Ren enss HM Senior Coroner, Bedfordshire and Luton Essex HM Coroners Office x SS14 7XX The Court House Woburn Street, a Ampthill ay Email: Bedfordshire MK45 2 HX "ES ay, Chief Executive: Sally Morris Your ref: 41091-2016 Dear Mr Osborne, | am writing to set out the Trust's formal response to the Regulation 28: Report to Prevent Future Deaths, dated 15 December 2016. ! would like to begin by extending our condolences to the family of Mrs McHale. | hope this response provides them and you with assurance that the Trust are taking the matter seriously and have an action plan to address the issues. Although the Trust welcomes your remarks in court which indicate that you have no concerns about the care of Mrs McHale, we also acknowledge the concerns raised with regards to the number of Tissue Viability Nurses (TVN) available within our community heaith services. In response to these, a service review has been undertaken. On reviewing the TVN service within the Trust, we can confirm that clear pathways are in place to ensure timely and effective referral to the service and we have increased the provision of TVN's available over the past two years. Further to this, the community nurses, although they are not TVNs, do have ongoing training and monitoring to ensure they are skilled in the prevention and early detection of pressure ulcers. All category 3 and 4 pressure ulcers acquired in our care are thoroughly investigated through root cause analysis and ‘Skin Matters’ panels to review care given and identify if any learning can be taken forward. The Trust remains committed to continue to take action to reduce the number of pressure ulcers in the community and we have worked with the CCG, local authority and acute hospitals to support pathways, training and raising awareness. MTUTUS SION Oye NS ian oy oer South Essex Partnership University er SS, ~ NHS Foundation Trust gy INVESTORS | _ “4 IN PEOPLE [soir 3 ' Stonewall | iv EE] www.septinhs.uk We have informed Bedfordshire CCG, who commissions our TVN service, of the outcome of the inquest. As a result, we are meeting with them shortly to further discuss reviewing the commissioned levels of TVN service in the community. Finally, | would like to reiterate my condolences to Mrs McHale's family. | hope that this response goes some way to providing assurance that the Trust regards their loss very seriously and has taken significant steps to review the TVN service and care and prevention of pressure ulcers in the community. Yours sincerely, Segt Soe Sally Morris Chief Executive
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