Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0459, written 21 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 | 21 Dec 2016 |
|---|---|
| Reference | 2016-0459 |
| Deceased | David Cooper |
| Coroner | Andrew Barkley |
| Coroner area | South Wales Central |
| 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.
ANNEX A 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: 1. Chief Executive of ABMU Health Board 2. Minister for Health, Welsh Assembly Government CORONER | am Andrew Roger BARKLEY, Senior Coroner for the coroner area of South Wales Central. 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. EWE cc PTY GPE O07 <1 <7 <1 c | INVESTIGATION and INQUEST On 6" April 2016 | commenced an investigation into the death of David Bassett COOPER aged 81. The investigation concluded at the end of the inquest, with a jury, on 15"" December 2016. The conclusion of the inquest jury was that of a narrative conclusion and the medical cause of death was recorded as 1a. Acute on chronic subdural haematoma (traumatic) 1b Recurrent Falls 2. Hospital Acquired Pneumonia. The narrative conclusion was “following a fail as an inpatient, Mr Cooper died of a traumatic brain injury, to which failure(s) in medical / nursing care contributed” 4 | CIRCUMSTANCES OF THE DEATH Mr COOPER suffered a traumatic head injury as a result of a road traffic collision in 1992, from which he recovered, and suffered a stroke in January 2009. He fell in the community and sustained a serious head injury on 12" October 2015 and was admitted to the Princes of Wales Hospital in Bridgend. Whilst in hospital, he was transferred between several wards and up to the time of his death, he suffered 9 separate falls. The final fall on 5" March 2016 caused a subdural haematoma from which he died. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] i. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient's risk of falls. For example, on ward 18 Mr Cooper was in receipt of “1:1” nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered. 2. The accuracy and completeness of nursing notes and records left much to be desired. For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary - a document which was supposed to act as a tool for nursing staff to assess whether there was a pattern to the numerous falls being sustained — save for the last fall on 5" March . This deprived staff of the opportunity to see the “whole picture” and to take into consideration the eight falls which he had sustained up to that point. 3. The evidence revealed that there was a distinct lack of “joined up” thinking and a failure to see the “whole picture”. Mr Cooper's risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls. 4. As with many other cases involving patients at high risk of falls, the evidence revealed shortcomings in the system used for booking additional staff to provide “4:1” care, revealing a system which left front line nursing staff unable to cope with the challenges in looking after the most vulnerable. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 by 15"" February 2017. 1, 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 | have sent a copy of my report to the Chief Coroner and who may find it | useful or of interest. ! 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. SIGNED: Dated: 2
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.
. GIG | Bwrdd techyd Prifysgol <1. .e. | Abertawe Bro Morgannwg NHS University Health Board Dyddiad/Date: 14! February 2017 @ 01639 683302 Alexandra Howells PRIVATE & CONFIDENTIAL Acting Chief Executive Mr A Barkley ABMU Health Board Coroner's Office 1° Floor Rock Ground Aberdare CF44 7AE Dear Mr Barkley, Re: David Bassett Cooper Inpatient at Princess of Wales Hospital, Bridgend, CF31 1RQ | write further to the Regulation 28 Report to Prevent Future Deaths in relation to Mr. David Bassett Cooper, received by Abertawe Bro Morgannwg Health Board from your department in December 2016. | have enclosed an Action Plan completed by Princess of Wales Directly Managed Unit and Mental Health Learning Disability Unit in retation to the four points highlighted in your report. | hope the enclosed Action Plan demonstrates the actions that have, and will continue to be taken, in relation to these issues and provides you the level of assurance that is required. The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency's Risk Assessments and | enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility. The Falls Management Group will continue to meet as a scrutiny panel to ensure that appropriate training and individual falls scrutiny is being undertaken along with continued review of performance data. Te Physician and Geriatrician, will be leading the Falls Management Group. See Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board Pencadlys ABM / ABM Headquarters, 1 Talbot Gateway, Port Talbot, SA12 7BR. Ffon / Tel: (01639) 683344 www.abm.university-trust.wales.nhs.uk If you require any further information in relation to the information contained in the Action Plan, please do not hesitate to contact me. Yours sincerely, Alexa Howells \ Acting Executive Abertawe Bro Morgannwg Health Board ey Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board Pencadlys ABM / ABM Headquarters, 1 Talbot Gateway, Port Taibot, SA12 7BR. Ffon / Tel: (01639) 683344 www.abm.university-trust.wales.nhs.uk
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