Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0163, written 18 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 May 2017 |
|---|---|
| Reference | 2017-0163 |
| Deceased | Alice Gibson-Watt |
| Coroner | Sarah Ormond-Walshe |
| Coroner area | West London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | London Ambulance Service 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Simon Stevens Chief Executive, NHS England, Skipton House, 80 London Road, SE1 6LH CORONER I am Sarah Ormond-Walshe, Assistant Coroner, West London jurisdiction 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, INQUEST On 26" November 2012 the court opened an investigation into the death of: Alice Amaryllis Gibson-Watt (“Alice”), She had died on 20° November 2012. The inquest was concluded on 27" April 2017. A jury found: That the medical cause of death was: la Hypoxic ischaemic brain injury 1b Cardiac arrest 1c Trauma to the liver 2. Post-partum steatosis How, when and where: On 14" November 2012, Alice Gibson-Watt was admitted to Chelsea & Westminster Accident & Emergency with suspected post-partum psychosis. She was medically assessed in A & E and found to be in good physical health. She was subsequently moved to Grosvenor Ward at Lakeside on 14°" November at 11.27 am and put into her own ward bedroom where post-partum psychosis was confirmed. Following deterioration of her mental state on 15'" November, Alice was placed in seclusion and administered the anti-psychotic drug Haloperidol (5mg IM). Seclusion started at 15.00 hours on 15 November 2012 and ended at 22.25. During this period, Alice was monitored within eyesight. However, monitoring and recording of vital signs were inadequate and insufficient and not in accordance with the Lakeside policy on observation and monitoring. Oral and written communication was poor and insufficient. Prior to Alice’s seclusion and the administration of Haloperidol, opportunities were missed for a thorough medical assessment and ECG. Considering the liver laceration, there was no evidence of trauma when Alice was admitted to Lakeside, but there was evidence that by 05.30 am on 16" November 2012 an injury to the liver had been sustained. It was probable that a liver injury was sustained whilst Alice was having a psychotic episode leading up to seclusion; her liver was more vulnerable due to post partum steatosis. Considering the cardiac arrest, Alice was found not breathing some time after 03.00 on 16" November 2012. She was checked for pulse and respiration by two separate members of staff. Lakeside alarm was raised around 03.15. A third, more senior member of staff arrived, removed Alice from the bed, checked pulse, airway and CPR was commenced sometime after 03.25. At 03.31 West Middlesex crash team and London Ambulance Service were called. The crash team arrived at around 03.34. LAS arrived at 03.35 outside Lakeside. There was a delay in the ambulance service entering the building due to a locked door to the unit and no member of staff to let them in. The defibrillator was used at 03.40 - despite there being a defibrillator available in the room it was not used by Lakeside staff. The defibrillator that was used was the one provided by LAS, Return of spontancous circulation began at 03.48. Alice was then fully intubated and ventilated and was taken to the ITU at West Middlesex Hospital. She was transferred to King’s College Hospital at 17.40 hours on 16" November 2012 due to further complications to the liver. Alice did not regain consciousness and died on 20" November 2012 at King’s College Hospital at 11.39 hours. The Conclusion of the Jury was: Hypoxic brain injury, caused by cardiac arrest, to which neglect and gross failure of Lakeside staff to commence CPR and use a defibrillator contributed. CIRCUMSTANCES OF THE DEATH Alice Gibson-Watt was a well 34 year old lady who had given birth to her first child a few weeks before she began to behave abnormally. She was behaving so psychotically on the evening of 13" November 2012 that her husband called for an ambulance. Alice was restrained by the ambulance staff, and then police, when she was taken to hospital. She was first a voluntary patient in a psychiatric assessment ward, Grosvenor ward at the Lakeside Mental Health Unit within the grounds of West Middlesex University Hospital and run by the West London Mental Health NHS Trust). Her diagnosis was post partum psychosis. Her behaviour became particularly chaotic and abnormal again on 15" November 2012 with Alice being aggressive. She was taken into seclusion and given 5mg Haloperidol intramuscularly, and sectioned under s5(2) Mental Health Act 1983. She was thereon particularly sleepy and tried to sit on the floor when being escorted back to her room over seven hours later. Approximately 12 hours after having been given the Haloperidol she went into cardiac arrest. She had been sleeping continually. At the time of the arrest she was being observed, on “eyesight” 1:1 observations by a nurse. The jury heard that there was some delay in recognising her cardiac arrest and starting effective CPR. She died of hypoxic brain damage later at King’s College Hospital on 20" November 2012. At the time that Alice was being observed, the Rapid Tranquillisation policy of the Mental Health Trust was not followed. The Rapid Tranquillisation policy directed that vital signs should be done every 30 mins until the patient is ambulatory and to include blood pressure, pulse and temperature. No ECG had been done, at a time when it was possible to do so, prior to the administration of Haloperidol. This is normally required to rule out an abnormal heart trace (prolonged QTc). A MEWS (modified early warning score) score of 1 was not acted upon. With or without the liver laceration at the time of cardiac arrest, Alice was presenting physically abnormally. The one set of observations taken temporally near to the cardiac arrest showed a pulse prima facie high (95 bpm) for a patient who was resting and Alice was very sleepy indeed and had been for a long time. Staff did not see cardiac arrests often in mental health settings and it was only the third member of staff examining Alice who properly identified CPR should start. When it did start, a defibrillator was not used immediately. CORONER’S CONCERNS During the course of the inquest, the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. - The sad facts leading up to the death of Alice have not been the first set of facts where I have heard about the death of a young mentally unwell patient being cared for on an acute mental health ward and who becomes acutely physically unwell, goes into cardiac arrest and where attempts at cardiac pulmonary resuscitation prove unsuccessful. Post-partum psychosis 1 in 1,000 new mothers suffer from the dreadfully disabling and distressing disorder of postpartum psychosis. I have carefully considered whether to focus in on the care of patients with post-partum psychosis in relation to any PFD report. This is because I do not consider 1 in 1,000 is a low figure. This is a disorder associated with young women and a disorder with a good prognosis and one would hope the mortality rate is low. The disorder is an acute psychiatric emergency and carries with it symptoms that can clearly be as severe as one can conceivably imagine. However, the facts surrounding Alice’s death raise issues involving arguably wider matters than the concentrating on the particular disorder itself. I have sufficient concern about a wider issue which warrants the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally. This is: The identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care. In Alice’s case, even before there were signs that she was physically unwell, there was no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health. No serial measurements of her observations meant that abnormalities could not be easily, or at all, identified once they occurred. In mental health units the threshold that prompts the use of regular vital sign observations appears to be high, and there maybe good reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Even when the NEWS (previously MEWS) system is in place - a process which is there to assist in the identification of patients who are becoming acutely unwell - it is not always followed. This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient. I am aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That seems like a big step in the right direction. | am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). I was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. T am aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future. As with the NEWS scoring system, predisposes that staff will accurately use, interpret and act upon abnormal observations appropriately. From what I have scen with the use of MEWS/NEWS scoring, this will be the challenge. Nurse Consultants in Physical Healthcare would be able to assist. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. The employment of Nurse Consultants in Physical Healthcare in acute mental health settings will assist in respect of training mental health practitioners such as nurses and healthcare workers in the identification of physically sick patients and thereon the appropriate escalation of those patients’ care. The installation of remote physiological monitoring at the current time, appears to have potential merit, although it is only as good as its operators. I would be grateful if NHS England would acknowledge my support for the use of Nurse Consultants in Physical Healthcare working in acute Mental Health settings. With or without technological advances to assist staff, the education and auditing of mental health professionals in identifying the acutely sick, and carrying out appropriate action, is vital to prevent future loss of life. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14" July 2017. I, 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. If you require any further information or assistance about the case, please contact the Coroner's Officer, [iin a COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: Alice’s family The West London Mental Health NHS Trust Chelsea & Westminster NHS Foundation Trust The Metropolitan Police Service London Ambulance Service NHS Trust I 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] [SIGNED BY opto 18" May 2017
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.
Sarah Ormond-Walshe INHS| England Professor Sir Bruce Keogh National Medical Director Skipton House 80 London Road SE1 6LH Assistant Coroner South London Coroner's Office, 2nd Floor /& August 2017 Davis House Robert Street Croydon CRO 10QQ Dear Ms Ormond-Walshe Re: Regulation 28 Report — Alice Amaryllis Gibson-Watt (died 20.11.12) | am writing in response to your prevention of future deaths report that was issued to Simon Stevens, Chief Executive of NHS England following the death of Mrs Gibson-Watt. Mr Steven's referred the matter to my office, asking that | provide a response to your Regulation 28 Report. The circumstances surrounding this death are extremely sad, given that Mrs Gibson-Watt had recently given birth to her first child and | would like to express my deepest sympathies to her family. The impact of mental health problems experienced by women in pregnancy and during the first year following the birth of their child can be devastating for both mother and baby, as well as their families. As part of the Five Year Forward View for Mental Health, NHS England has committed plans so that by 2020/21, support will be available for at least 30,000 more women each year to access evidence-based specialist mental health care during the perinatal period. This will include access to psychological therapies and the right range of specialist community or inpatient care so that comprehensive, high-quality services are in place across England. As indicated in your letter, | read it that your concerns are wider than concentrating on the level of care patients who present with post-partum psychosis receive, but that they extend to identifying acutely physically unwell patients being nursed in an acute mental health setting, and the escalation of appropriate care. | have involved colleagues from the NHS England Perinatal Mental Health team in considering how best to respond to your concerns and they have provided the responses set out below:-. High quality care for all, now and for future generations Siaff within mental health settings should have the necessary core competencies and skillset to recognise physical ill health, risk of or deterioration of physical health, perform a methodical initial assessment and initiate appropriate management. Care Quality Commission (CQC) inspections in mental health settings particularly look for evidence of employment of (or suitable arrangements to provide) medical, nursing and pharmacy staff and other healthcare professionals with the necessary skills and knowledge to oversee and deliver aspects of physical healthcare. Whilst NHS England does not mandate which specific job roles should deliver which elements of the physical health care agenda in mental health settings, staff should be competent with the appropriate training and ongoing CPD to meet the full needs of patients. Health Education England (HEE) encourages that all members of the mental health team are appropriately skilled and competent to perform their roles and responsibilities in addressing the physical health needs of their service users. Access to relevant physical health training should be provided and ongoing development should be supported through strong leadership. This could be leadership from a nurse consultant, it could also be from a GP, a physician associate or a clinical resuscitation officer. An example of a multi-disciplinary course which is freely available online and commissioned by HEE is, Recognising and Assessing Medical Problems in Psychiatric Settings (RAMMPS). This course is explicitly focusing on medical, nursing and support staff as well as other professional groups in recognising the deteriorating patient, providing good care and managing safe patient outcomes, httos://hee.nhs.uk/hee-your-area/yorkshire-humber/education- training/multi-professional-workforce/clinical-skills-simulation/recognising- assessing-medical-problems The national Physical Health SMI CQUIN supports the improvement of physical healthcare to reduce premature mortality in people with serious mental illness (SMI). The CQUIN although concerned with altering cardio vascular risk for this population also mandates high quality programmes for all clinical staff caring for people with SMI. The scope of the CQUIN includes inpatients wards, early intervention in psychosis services and community mental health teams. In parallel, NHS England continues to support the ongoing inspection and regulation of mental health inpatient wards by the CQC. CQC require that all providers implement safe and effective systems for identifying and responding to the deteriorating patient including application and audit of compliance with the National Early Warning Score- NEWS. NHS England encourages researchers and clinical teams to optimise and investigate opportunities that new technologies may present to improve the physical health care of those with mental health needs. At this time the evidence base is not sufficient to specifically recommend remote vitals monitoring but we continue to encourage innovation in this area. High quality care for all, now and for future generations | hope this response containing details of the areas that are being focused on gives you the relevant assurances you require. If you have any further queries or concerns please do not hesitate to be in touch. Yours sincerely, Cua Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England High quality care for all, now and for future generations
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