Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0462, written 22 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 | 22 Dec 2016 |
|---|---|
| Reference | 2016-0462 |
| Deceased | Edwina Moses |
| 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
lam Andrew Roger BARKLEY, Senior Coroner for the coroner area of South Wales
Central.
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.
INVESTIGATION and INQUEST
On the 23“ September 2016 | commenced an investigation into the death of Edwina
Rose Moses aged 78. The investigation was concluded at an end of an inquest dated
the 20" December. The conclusion of the inquest was that of a narrative conclusion
namely “Edwina Rose Moses, who suffered from complex health issues and dementia
died as a result of an upper gastrointestinal bleed having undergone surgery to repair
two broken hips after a fail at her home address and a fall in hospital at a time when she
was assessed as requiring one to one care”.
4 | CIRCUMSTANCES OF THE DEATH
The deceased was admitted to hospital on the 15™ August having fallen at her home
address fracturing her left neck of femur. That was surgically repaired on the 18"
August after which, despite some setbacks in terms of respiratory function, she
appeared to be making a recovery. She fell from her hospital bed on the 31" August at
a time when she should have been receiving one to one nursing care. She fractured her
tight hip which was surgically repaired the same day. In the following days she became
increasingly unwell showing signs of a gastrointestinal bleed and deteriorated and
assed away on the 19" September 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. —
[BRIEF SUMMARY OF MATTERS OF CONCERN]
The evidence revealed that there was a poor system in place for requestin I
additional nursing cover to provide one to one support. There was confusion by ;
front line staff as to who was responsible for identifying, booking and ensuring
that such help was provided.
2. The evidence showed that it was common place for additional nursing cover not
to attend and staff were then left to provide one to one cover alongside their
main stream duties — which was wholly unrealistic. Given the apparent
frequence in which additional nursing cover is “unavailable”, often in the context
of dealing with patients suffering with dementia, the issue of appropriate staffing
levels on wards and the ability of staff to safely look after patients must be a
concern.
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. |, 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 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:
2zir{ie
tN
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.
G IG Bwrdd lechyd Prifysgol ar a. | Abertawe Bro Morgannwg N HS University Health Board Dyddiad/Date: 14" February 2017 = ee PRIVATE & CONFIDENTIAL Renee veieeecuire Mr A Barkley ABMU Health Board Coroner's Office 1* Floor Rock Ground Aberdare CF44 7AE Dear Mr Barkley, Re: Edwina Rose Moses Inpatient at Princess of Wales Hospital, Bridgend, CF31 1RQ | write further to the Regulation 28 Report to Prevent Future Deaths in relation to Mrs. Edwina Rose Moses 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 in relation to the two 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 Princess of Wales Hospital Managed Unit has reviewed its process around enhanced observation. The review included the standard of completion of Risk Assessments and introducing a process to monitor staffing levels across the site which will include the identification of all patients requiring enhanced observation. There is daily monitoring of staffing levels in place which is subsequently handed over to the Out of Hours team for evenings and weekends. All staff have been made aware of the process to check the Nurse Bank system. This work will link into the Health Board Falls Management group as prevention of falls is one of the main criteria for requesting enhanced observation. An audit process has been introduced across the Princess of Wales Hospital Managed Unit in February 2017 to monitor adherence to the all elements of the Increased Nursing Observation Guidelines. 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) 683244 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, Acting Chief Executive Abertawe Bro Morgannwg Health Board Encs: Action Plan Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleo! 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
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