Prevention of Future Deaths reports · 2016

Leslie Lerner

Regulation 28 report to prevent future deaths, reference 2016-0487, written 28 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report28 Oct 2016
Reference2016-0487
DeceasedLeslie Lerner
CoronerVeronica Hamilton-Deeley
Coroner areaBrighton and Hove
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

VERONICA HAMILTON-DEELEY, LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove

THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON

BN2 30B

Assistant Coroners

CATHARINE PALMER LL.B (HONS)
KAREN HENDERSON, BSC,BM,MRCPILFRC. -
GILVA D.J.TISSHAW, BA(LA W)HONS

Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047

CORONERS SOCIETY OF ENGLAND AND WALES
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

THIS REPORT IS BEING SENT TO:

4. Dr. Gillian Fairfield, Chief Executive, Brighton and Sussex University
Hospital NHS , Royal Sussex County Hospital, Eastern Road, Brighton

CORONER

fam Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and
Hove

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 2012.

3
INVESTIGATION and INQUEST

On 7" June, 2016 | commenced an investigation into the death of Leslie Isaac
LERNER. The investigation concluded at the end of the inquest on 18" October,
2016.The conclusion of the inquest was a NARRATIVE CONCLUSION.

| CIRCUMSTANCES OF THE DEATH

| See Record of Inquest

VERONICA HAMILTON-DEELEY, LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove

THE CORONER'S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON

BN2 3QB

Assistant Coroners

CATHARINE PALMER LL.B (HONS)
KAREN HENDERSON, BSC,BM,MRCPI,FRC..
GILVA D.J.TISSHA W, BA(LA W)HONS

Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047

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:

13°" May 2016

(1) Junior Doctor applied wrong sling with wrong knot for Mr Lerner after she
had learned that he had had a fractured shoulder which was to be treated
conservatively.
| heard that a Nurse should have applied the sling because the
chances are that he or she would have known which sling to use and
how to apply it.

(2) Although the Junior Doctor discussed Mr Lerner with her Senior, the Senior
did not actually see him nor specifically state which type of sling (should
have been a collar and cuff) should be applied.
| was told that the Senior should always see the Patient.

14" May 2016

(1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and |
towards the middle of the day he was discharged without a Senior Review.
| was told that before he was discharged he should have been seen by
a Senior Doctor and it may well have been that the inappropriately
applied sling would have been recognised.
He was sent home with no analgesia. He should have been given |
analgesia. It became clear from the evidence that the pain that he suffered
was very much part of his overall deterioration and an exacerbating factor |
with his dementia. i
The Hospital’s own Discharge Protocol was not followed, it should |
have been. |

VERONICA HAMILTON-DEELEY, LL.B.
Her Majesty’s Senior Coroner

THE CORONER’S OFFICE
WOODVALE, LEWES ROAD

for the City of Brighton & Hove BRIGHTON
i BN2 3QB

AAG KS AN
Assistant Coroners fa 2 iby Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) ces at Fax: Brighton (01273) 292047

KAREN HENDERSON, BSC,BM,MRCPI,FRC. .
GILVA D.J.TISSHA W, BA(LAW)HONS

(1)

(1)

(2)

15th May 2016

Mr Lerner was back at the RSCH, by ambulance at 1006 hrs in
considerable pain and discomfort. He was seen by the Consultant in
Elderly Medicine at 1645 and was given analgesia at 1700 hrs — ie almost 7
hours after he arrived at the hospital.

This is completely unacceptable, this man was in pain from the fracture and
he should have been given pain relief.

At that stage he should also have been reviewed by the Orthopaedic
Team, no such review was organised.

16" May 2016

Having been admitted to a renal ward, because of lack of beds
elsewhere, a member of the medical staff had a telephone discussion
with a member of the Orthopaedic Team and a collar and cuff sling was
recommended. This information was not passed onto the Nursing Staff,
not properly documented nor was the Patient actually seen by a member
of Orthopaedic Team. He should have been seen and a note should
have been made.

He then was moved to another ward, again not an Orthopaedic Ward,
where any chance of correct hand over seems to have been lost because
he was transferred to Baily Ward in the middle of the night. No proper
handover.

There was no referral to physiotherapists and yet the Trusts own
paperwork says that exercises should be given by a Physiotherapist and
commenced by the patient after seventy two hours of the fracture
occurring. No speedy referral to physiotherapists.

Within his notes was an utterly inadequate document explaining what the
Patient needs to do with a fractured shoulder, however, as the Ward
Manager pointed out it does not say what type of sling should be applied
for this particular Patient and so she apparently had no idea anything was
amiss. This document was not fit for purpose either for the patient or
the ward.

VERONICA HAMILTON-DEELEY, LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove

Assistant Coroners

CATHARINE PALMER LL.B (HONS)

THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON

BN2 30B

Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047

KAREN HENDERSON, BSC,BM,MRCPIFRC. .
GILVA D.J.TISSHA W, BA(LAW)HONS

17" May — 22" May 2016

There is no evidence of any continuity of care.

There is good evidence of “hands off” care and nursing.

In spite of anxieties expressed by the Manager of Mr Lerner’s Rest Home,
who came to assess him on the 19" May having been told he was
medically fit for discharge (which he was not) and by his nephew Mr
Marsh that he seemed ‘chesty’ and so far as the Manager was concerned
that she was worried about the sling which did not seem to be supporting
his elbow and did not seem to be ‘right’, there was no appreciation of the
possibility that the sling was causing half the problems at least that Mr
Lerner was suffering.

No efforts were made to see whether he was ‘chesty’; a Doctor was not
called, another chest x-ray was not ordered and it was not until the next
day he was found to have a bilateral pneumonia which needed
intravenous antibiotics.

In addition he was being nursed at the wrong angle and it seems clear
that he couldn’t have been given any personal care such as washing,
because if he had been, nursing staff or healthcare assistants would have
seen the tightness of the sling and the damage that it was causing.

22"? May 2016

(1)

This was the day (nine days after its application) that hospital staff
realised that the sling was incorrectly tied, and of the wrong type, and
had caused a long deep Grade 2 pressure sore and necrotic ulcerated
area where it had been pressing into the back of Mr Lerner’s neck.
Every time he was moved and repositioned this wound will have chaffed
and given him extra pain.

With regard to his medications: these were either given at a level at which he
was completely unable to communicate and co-operate and unable to realise that
his family were visiting him, or left him in such pain that he was quite unable to
manage it, as a result of this, his dementia and confusion worsened.

A wound care nurse referral was made on the 22" May and he was seen on the
23° May at 2 p.m.

VERONICA HAMILTON-DEELEY, LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove

THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON

BN2 30B

Assistant Coroners

CATHARINE PALMER LL.B (HONS)
KAREN HENDERSON, BSCBMMRCPLERC.. -
GILVA D.J.TISSHA W, BA(LAW)HONS

Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047

It was not possible now to apply any sling and it wasn’t until a few days after that,
that any careful thought was given to supporting his arm and shoulder in such a
way as to minimise the pain.

From the notes, once the sling had been removed Mr Lerner himself appeared
brighter and less confused, however this improvement was short lived.

He deteriorated but end of life care was not initiated until the 31°! May and he died
at 0835 hrs on the morning of the 3 June. In Court the Elderly Care Consultant
accepted that there had been delay in recognising Mr Lerner as a dying patient.

This case showed evidence of lack of communication, lack of care, lack of
continuity of care, too much use of ‘virtual’ clinics and a general “hands off” attitude
towards this patient.

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.

7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 18" January, 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.
8

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

1.  - Nephew
2 RE Manager, Brittany Lodge Rest Home, 32 Brittany Road, Hove
3. Secretary of State for Health, Department of Health |
4. Simon Stevens — Chief Executive NHS England

5. Care Quality Commission

wa

THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON

BN2 3QB

VERONICA HAMILTON-DEELEY, LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove

CATHARINE PALMER LL.B (HONS) Se Fax: Brighton (01273) 292047
KAREN HENDERSON, BSCBMMRCPLERC.. .
GILVA D.J.TISSHAW, BA(LAW)HONS

Assistant Coroners Telephone: Brighton (01273) 292046

| have also sent it to:-

1. ER Medico Legal Department, Royal Sussex County Hospital,
2. EE), Ward Manager, Baily Ward, Royal Sussex County Hospital,
Eastern Road. Brighton

a Consultant in Elderly Medicine, Royal Sussex County
ospital, Eastern Road, Brighton.
i Consultant in Emergency Medicine, Royal Sussex County

Hospital, Eastern Road, Brighton

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.

Date: 28" October, 2016 SIGNED BY:

Veronica HAMILTON-DEELEY

Senior Coroner Brighton and-Fove

Related reports

Other reports by Veronica Hamilton-Deeley

See all →

More reports categorised “Hospital Death (Clinical Procedures and medical management) related deaths”

See all →

Track Hospital Death (Clinical Procedures and medical management) related deaths

See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.