Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0075, written 16 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Mar 2017 |
|---|---|
| Reference | 2017-0075 |
| Deceased | James Mallett |
| Coroner | Yvonne Blake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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: Chief Executive Queen Elizabeth Hospital Gayton Road King’s Lynn Norfolk PE30 4ET 1 Tam Yvonne Blake Area Coroner, for the coroner area of NORFOLK 2 | CORONER’S LEGAL POWERS I 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 24 November 2016 | commenced an investigation into the death of James Charles MALLETT, 93yrs of age. The investigation concluded at the end of the inquest on 14 March 2017. The conclusion of the inquest was given in a narrative form (see attached). The medical cause of death was 1a) Subdural Haemorrhage, 1b) Fall and 1c) Parkinson's disease. : . 4 | CIRCUMSTANCES OF THE DEATH Mr Mallett was admitted to hospital after a fall at home. Whilst an inpatient he fell again and sustained a fatal head injury. He was put back to bed and a doctor called, this doctor appears to have arrived some two hours later. There was no attempt by the nursing staff to secure his more urgent attendance. They did not ask for help from the night team. The neurological observations carried out were unclear and not of an acceptable standard or in a-timely manner. In addition when the doctor did arrive he ordered a CT scan (urgent) and after seeing the results showing a massive intracranial bleed, then ordered neurological observations to done two hourly which is not as per hospital guidelines. 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 duly to report to you. The MATTERS OF CONCERN are as follows. — [1) It became clear during evidence that the nursing staff on duty on 13 November 2016 were not able to understand and carry out proper neurological observations. This became evident when on one set of observations the nurse assessed Mr Mallett’s Glasgow Coma scale (GCS) as 3 (lowest score possible) and yet still had equal power in all four limbs which would not have been possible to assess. Some of the observations contradicted each other with one nurse assessing the patient as 6 on the GCS. (2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient. The nursing staff, who were described by Sr Snowden as a “junior aC IS Ee , workforce” did not seem to understand the seriousness of the injury and did not seek senior help from the night team. The nursing staff did not carry out regular and/or timely neurological observations. (3) The nursing staff made no contemporaneous notes for a period of five hours on the system so there Was little information about the timings of their actions. The doctor did not arrive until over two hours. later but did order an urgent CT scan, however when he had the results he then ordered neurological observations be done every two hours which is not as per hospital protocol. 4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor. 5) There do not appear to be systems in place at the hospital which are sufficient to recognise when nurses are so inexperienced and/or lacking in training that they cannot undertake basic observations on a patient following an injury of this kind. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 11 May 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 to the following Interested Persons: . * ERE (Nicce) | have also sent it to: * Department of Heaith * Healthwatch Norfolk 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. Dated: 16 March 2017 Area Coroner Yv e Blake,
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.
2.8 APR 2017 NHS| The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Gayton Road ; Kings Lynn 24 April 2017 Norfolk PE30 4ET www.qehkl.nhs.uk Ms Yvonne Blake = F Interim Director of Nursing HM Area Coroner Tel: 01553 613133 69 — 75 Thorpe Road Fax: 01553 613741 Norwich Minicom: 01553 613888 NR1 1UA Email Dear Ms Blake The Regulation 28 report dated 16 March 2017 - Concerning the late Mr James Mallett | write in my capacity as Interim Director of Nursing to respond formally to the Regulation 28 Report. | would like to assure you that the matter of in-patient falls within the organisation is taken very seriously and considered regularly at Board level, and by the Non-executive Directors and Governors. We have an ongoing plan in relation to falls and falls risk in all relevant areas of the Trust and did so at the time of this sad incident involving Mr Mallett but wish to advise that this plan is subject to upgrading, modification and re-appraisal_at regular intervals and also at any time when an incident like this prompts a re-look. in post as our new Medical Director this month and | have discussed this case with him to ensure learning from this event is shared with the medical teams. A review of the RCA action plan for the fall in question has been undertaken. Further actions taken since this was presented to you at the hearing on 14 March by HR include the following: e Acopy of the Regulation 28 notice has been given to each nurse on Windsor and the results of the RCA are being discussed at the ward meeting on 26th April 2017. ¢ Acopy of the RCA and Regulation 28 notice has been shared with the senior nurses in A&E to discuss with their respective teams. e A falls campaign was launched on 26th January 2017 and work is on-going with the sisters, charge nurses and matrons to ensure clinical staff are fully aware of the falls assessment process. e Training is on-going on Windsor ward by the falls co-ordinator on the assessment of patients who may be at risk of falls and falls champions have been identified on the ward. ¢ Windsor ward piloted a newly devised bed rails assessment document in March 2017. This is to be completed every 24 hours and audits are planned to assess compliance at the end of April 2017 and the effectiveness of the tool prior to a Trust roll out. ¢ The falls intranet site has been set up with all the resources required to support the safe assessment of patients in relation to falls. e The new policy for the assessment of patients that require increased observation was ratified in December 2016 and is now in place. This includes clear guidance of how to allocate 1:1 care. 25 April 2017 The Queen Elizabeth Hospital King’s Lynn NHS Trust In relation to the question regarding neurological observations: e A training programme has been devised for Registered Nurses on the undertaking and interpretation of neurological observations. A pack and the slide presentation (teaching tools) has been shared with the teams in the Emergency division with Trust-wide training that commenced on 10th April 2017. e All Registered Nurses in inpatient and access areas will be required to undertake this training programme with a test to demonstrate competence. ° The Trust has updated the mandatory training days to include clinical scenarios in relation to the care following a fall, and in future this will also be part of induction for new starters and returners (e.g. following maternity leave). | hope that this provides you with the detail required, please do not hesitate to contact me if you require anything else. | would be delighted to meet with you if you would like to discuss any aspect of nursing care at the Trust. Yours sincerely Interim Director of Nursing Page 2 of 2
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