Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0023, written 25 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jan 2017 |
|---|---|
| Reference | 2017-0023 |
| Deceased | Raymond Pollard |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS 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.
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,MRCPIFRC. - GILVA D.J.TISSHAW, BA(LAW)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: 1. Brighton and Sussex University Hospitals NHS Trust, PF 2. Dr Gillian Fairfield, Chief Executive, Brighton and Sussex University Hospitals NHS Trust 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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. 3 INVESTIGATION and INQUEST On 25" July, 2016 | commenced an investigation into the death of Mr Raymond Frank POLLARD. The investigation concluded at the end of the inquest on 19" January, 2017. The conclusion of the inquest was a Narrative Conclusion. 4 CIRCUMSTANCES OF THE DEATH At the Inquest | heard evidence concerning the failed discharge which took place on the 28" Jun 2016. Mr Pollard came into hospital as an emergency on the 10" June with a community acquired pneumonia. He spent several days in the intensive care unit before being transferred to the respiratory ward. . The main problems related to his respiratory difficulties and his renal problem which were resulting in metabolic acidosis and high potassium levels. These conditions needed treating and monitoring. Arterial blood gases revealed that Mr Pollard was improving but from the 25" June and through the 26" and into the 27" June he was quite unwell with potassium levels at 5.6, 5.7, 6 (in the early hours of 27/6) and 5.8 on the 27" at 10 a.m. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner os THE CORONER’S OFFICE WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON Sc BN2 3QB Assi Cc IRE Telephone: Brighton (01273) 292046 ssistant Coroners cs Si ES) elephone: Brighton CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPLFRC. - _ GILVA D.J.TISSHAW, BA(LAW)HONS * Fax: Brighton (01273) 292047 PH levels were also giving rise to some concern. At a ward round on the 27" June (09.50 hrs) a decision was made that he was fit for discharge ‘today’. There were no further arterial blood gases done, therefore no further checks on his potassium levels and his PH. Mr Pollard was not seen again by a Doctor prior to his discharge. NEWS scores were kept during the 25", 26", 27" and 28" June. At Inquest | was told that his average or baseline was probably between 3 and 4 or possibly 3 and 5. On the 25" his four NEWS scores were 1, 4, 3. and 2 On the 26" his four NEWS scores were 4, 7, 5 and 7 On the 27" his four NEWS scores were 6, 8, 10, 6, 1 and6 On the 28" (06:05 hrs) the last time they were calculated his NEWS was 6 Therefore on average above his baseline. Mr Pollard was moved from Catherine James Ward to Overton Ward on the 27". He went to the discharge lounge at 10 to 10.20 hrs there was no ward round involving him and no reassessment of him before he was discharged which according to the Discharge Summary happened at 11.30 hrs. He arrived at his rehab nursing home at midday having walked from the ambulance to his room (he had not taken any substantial amount of exercise since he had been admitted on the 10" June). It became clear that he was very shut down and unresponsive and obviously unwell. Some four hours after he had arrived, after persuasion by his wife, an ambulance was called and he was found to be extremely unwell with a NEWS of 8. He was taken urgently to the Royal Sussex County Hospital, Brighton where a chest x-ray showed progression of chest consolidation and where at 1800 hrs that day his PH was low at 7.2 and his potassium level was high at 8. Mr Pollard effectively needed resuscitation and decisions about his treatment. Within a couple of days his status had changed from someone who was fit to be discharged to a rehabilitation unit to a seriously unwell patient who was not fit for haemo filtration, whose ceiling of care would be ward based and by the 4" July end of life medications were put in place and he was placed on the end of life pathway. The evidence to me at the Inquest was that the Hospital accepted that this was unsatisfactory. It will review its discharge practices and will also give consideration 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,MRCPLFRC. _ GILVA D.J.TISSHA W, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 to ensuring a medical review prior to discharge in a complex patient with fluctuating ‘numbers’ where the patient has not been discharged within 18 to 24 hours of the discharge decision. 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) A poorly informed decision to discharge made for a patient with no real Improvement in his condition. (2) The patient was not seen again by a doctor or reviewed as to suitability for discharge. (3) As a result the discharge failed and this failure seriously compromised Mr Pollard. 6 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 14" April 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. 2. 3. Secretary of State for Health, Department of Health 4. Simon Stevens — Chief Executive NHS England | am also under a duty to send the Chief Coroner a copy of your response. 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) a KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 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 Date: 25" January 2017 ; EB BY: Senior Coroner Brig id Hove
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.
Your ref: VHD/TS/INQ Our ref: GF001/KK 12 April 2017 Miss Veronica Hamilton-Deeley HM Senior Coroner Brighton and Sussex NHS | University Hospitals NHS Trust The Royal Sussex County Hospital Eastern Road Brighton BN2 5BE Tel: 01273 696955 Coroner’s Office Woodvale Lewes Road BRIGHTON BN2 3QB Dear Miss Hamilton-Deeley The late Mr Raymond Frank Pollard, DoB: 27/6/1931 NHS No: 468 098 6298 Thank you for your letter of 26 January 2017 and for drawing your concerns tol attention 2: Interim Chief Executive and has now left the Trust). 1am very sorry to read about the circumstances of Mr Pollard’s death and the concerns which you have highlighted. These issues have been reviewed by senior medical and nursing staff, including the Trust's Head of Nursing, Discharge and Partnerships, to identify improvements required within the Directorate and to ensure that learning from this case is shared with staff in Respiratory Medicine. You asked us in particular to give consideration to ensuring a medical review prior to discharge in complex patients with fluctuating clinical signs where the patient has not been discharged within 18-24 hours of the discharge decision. It is a key principle of our discharge policy that once the decision has been made that the patient is medically ready for discharge (MRFD), the patient's discharge is then led by nursing staff. It is the responsibility of nursing staff to monitor the patient's condition and alert the medical staff if there are any concerns, including any change in a patient's condition. After reviewing Mr Pollard’s care, it is apparent that opportunities were missed on the morning of 28 June 2016 both to carry out additional assessments following the last NEWS assessment at 06:00 and to alert medical staff of Mr Pollard’s symptoms during the night of 27 June. It is concerning that following Mr Pollard’s transfer from Catherine James Ward to Overton Ward on the morning of 28 June, there is no documentation in the nursing evaluation notes by Overton staff. This would have confirmed how the staff on Overton Ward received Mr Pollard and what handover was given to the day shift staff concerning Mr Pollard’s condition during the night of 27 June, which had been documented in detail by the night nursing staff on Catherine James Ward. There had also been an opportunity for a further medical assessment of Mr Pollard during the day on 27 June (and after the morning ward round when it was decided that he was ready for discharge) when the Critical Care Outreach Team (CCOT) came to review him. This was a follow up to discussions between Respiratory Medicine and ITU medical staff early that With our partner Gong brighton and sussex “> medical schoo! morning. The CCOT was advised by medical staff on the ward that their intervention was no longer necessary. With hindsight, it would have been beneficial if the CCOT had reviewed Mr Pollard, as this would either have provided further evidence that his condition remained stable or alternatively, could have identified any deterioration since the morning ward round or any other concerns about readiness for discharge. | do understand your concern about continuing medical review of complex patients following a decision that they are ready for discharge. The Trust is committed to ensuring that all available medical resources are used as effectively as possible; this includes prioritising those patients who will most benefit from direct medical input, rather than providing automatic medical review of all patients. The medical team does review the progress of all MRFD patients on the daily “board round” and will follow up any issues identified either as a result of that process, or arising from any request from clinical colleagues, including nurses. It is very important, therefore, that existing Trust policies are followed from the point when the patient's discharge becomes nurse-led, in responding to changes in patients’ symptoms and appropriately requesting medical input. It is equally important that nursing documentation should be adequate. At the time of Mr Pollard’s admission, Overton Ward was designated for the care of patients from a range of clinical specialties who had been assessed as medically ready for discharge, and there was no lead Consultant for the ward. Since then, Overton has become part of the Respiratory Medicine Unit, together with Catherine James and Egremont Wards, as wards specifically for Respiratory Medicine patients. There is now a dedicated Respiratory Nursing team for the whole Unit, which also has a lead Consultant, and we try to ensure that a Junior Sister from the Respiratory Team is on duty on Overton Ward each day. This has greatly improved continuity of care for patients and communication within the team and we are confident that this will enhance the safety of respiratory patients approaching discharge. Events surrounding Mr Pollard’s discharge are being raised with nursing and medical staff through the Directorate clinical governance meetings and training/awareness sessions for staff which will continue this year, as a means of ensuring learning. These will focus on ensuring adherence to existing policies in respect of: i) discharge procedures, ii) responding to changes in patient NEWS scores and other clinical indicators, and iii) appropriate documentation, particularly when a patient is transferred between wards In light of your findings, Mr Pollard’s care, which was first discussed at the Respiratory Morbidity and Mortality Meeting in 2016, will be explored again at the next available meeting. It will also be raised at the Trust-wide Deteriorating Patient Steering Group meeting later this month, which is chaired > Deputy Medical Director, Safety & Quality. Any additional learning identified in nese meetings will be disseminated to medical and nursing staff. A further issue which arose was the mode of Mr Pollard’s transfer from the ambulance to his room at Victoria Highgrove Nursing Home and | understand that Mrs Pollard expressed concern at the inquest that Mr Pollard had walked a long distance from the vehicle to his room. | can confirm that the Trust booked a “sitting” ambulance for Mr Pollard’s discharge. Our expectation was that Mr Pollard would be transferred by chair at all times between the hospital and his room at the Nursing Home, based on the level of his mobility while he was in hospital. Mr Pollard was transferred by private ambulance through a company named WANT. | appreciate that we cannot be certain what happened on that day but | will send a copy of this response to the Care Quality Commission, as previously requested by them, in order that they can consider this issue further. | hope that the above information is helpful and thank you again for raising your concerns with the Trust. | would also be grateful if you could pass on my condolences to the family and friends of Mr Pollard for their sad loss. Yours sincerely f tge Findlay Executive Medical Director o Inspection Manager, Care Quality Commission
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