Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0225, written 8 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Sep 2017 |
|---|---|
| Reference | 2017-0225 |
| Deceased | Terence Ryan |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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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: 1. Mr Andrew Foster, Chief Executive, The Wrightington, Wigan and Leigh NHS Foundation Trust, The Elms, Royal Albert Edward Infirmary, Wigan Lane, Wigan WNi 2NN 2. The Senior Partner, The Grasmere Surgery, Leigh Health Centre, The Avenue, Leigh WN7 1HR 1 | CORONER I am Alan Peter Walsh, HM Area Coroner for the Coroner Area of Manchester West. 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. INVESTIGATION AND INQUEST On the 24 November 2016 I commenced an Investigation into the death of Terence Ryan, 59 years, born 29" September 1957. The Investigation concluded at the end of the Inquest on the 24" August 2017. The Medical Cause of Death was:- Ia_ Pulmonary Thromboembolism Ib Deep Vein Thrombosis Ic_ Left Lower Limb Trauma The Conclusion of the Investigation was that Terence Ryan died as a consequence of injuries sustained in a Road Traffic Collision where no anti- coagulation treatment was available to him following his self-discharge from Hospital. CIRCUMSTANCES OF THE DEATH 1. Terence Ryan (hereinafter referred to as “the deceased”) died at | n the 14" November 2016. 2. In August 2014 the deceased had a right Deep Vein Thrombosis in his thigh and a Pulmonary Embolus. In April 2015 the deceased had a further investigation for Deep Vein Thrombosis and it was not clear if this related to his previous Deep Vein Thrombosis or if this was a new event but he was commenced on Dalteparin injections as an anti-coagulant for three months. Dalteparin was subsequently changed to Rivaroxaban but this caused him to collapse and the Rivaroxaban was stopped and the Dalteparin injections restarted. On the 15" July 2016 the deceased attended the Deep Vein Thrombosis Clinic when a Consultant prescribed Edoxaban 60mgs per day for long term anticoagulation on weekly repeat prescriptions to be issued by the General Practitioner. However when the Clinic letter was received by the General Practitioner from the Consultant, the prescription of Edoxaban was not added to the deceased's repeat prescriptions. The deceased had further consultations with the General Practitioner on the 10" August 2016, 30° September 2016 and the 14" October 2016 and during that time he had complained about pain and swelling in the leg and a repeat prescription for his medication had been issued. However, the anticoagulation was not discussed at the appointments and the repeat prescriptions did not include Edoxaban. Accordingly, the deceased did not receive Edoxaban or any other anticoagulation medication from the 15" July 2016, when the Consultant issued a prescription, until the date of his admission to the Royal Albert Edward Infirmary, Wigan on the 3’ November 2016. The General Practitioner giving evidence at the Inquest confirmed that, when the Clinic letter relating to the prescription of Edoxaban had been received by the Surgery, the prescription had not been added to Mr Ryan’s repeat prescriptions, as it should have been, and the anticoagulation had not been considered at subsequent appointments. On the 3 November 2016 the deceased was in collision with a motor vehicle whilst crossing Atherleigh Way, Leigh at the junction with Kirkhall Lane, Leigh. He sustained a tibia fracture to the left leg and he was taken to the Royal Albert Edward Infirmary, Wigan, where the fracture was treated conservatively with a plaster cast and splint and he was admitted to the Hospital for physiotherapy and non-weight bearing non-operative treatment. In Hospital he was prescribed Dalteparin as prophylactic anticoagulation, which was to be continued for two weeks from the time of his admission. On the 10 November 2016 the deceased discharged himself from the Hospital against medical advice and he left the Hospital without any anticoagulation medication. The Dalteparin prescribed in the Hospital was not given to him because he walked out of the Hospital without waiting for a discharge notice and medication. Furthermore the Edoxaban, prescribed by a Consultant on the 15" July 2016, had not been included on the repeat prescriptions by the General Practitioner. On the 10 November 2016 at 12:30 hours a Doctor had a bleep from the 10 Ward where the deceased was receiving treatment and the Doctor was informed that the deceased wanted to discharge himself immediately. The Doctor met the deceased and tried to establish the reason for his self- discharge and the Doctor discussed the treatment and the mobilisation plan with the deceased. The Doctor explained the need for the deceased to stay in Hospital, particularly in view of the previous history of Deep Vein Thrombosis. The deceased agreed to stay in the Hospital but at 13:00 hours on the same day the Doctor received another call from the Ward stating that the deceased had decided to discharge himself from the Ward, against medical advice, and he had walked off the Ward and left the Hospital. The Doctor was concerned that the deceased had left the Hospital and he asked a Nurse in charge of the Ward as to the Hospital protocol when a patient self-discharges against medical advice. The Doctor was told by the Nurse that there was no protocol and he did not need to take any further action. Following the deceased’s self-discharge from the Hospital on the 10" November, 2016 there is no record of any contact with the General Practitioner and no record of any further contact with the Hospital. . On the 14™ November 2016 he was found in a collapsed and unresponsive condition at his home address at en] Leigh when he was diagnosed as having died. 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. During the Inquest evidence was heard that:- i. On the 15™ July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22™ July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10" November 2016. The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:- Ww a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment. b. In respect of discharge letters directing new medication — the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time. However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13" September 2016, the 30" September 2016 and the 14‘ October 2016 without the omission being checked. ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as a vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self- discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. 2. Irequest the Senior Partner of the Grasmere Surgery, Leigh Health Centre, The Avenue, Leigh, to conduct a review of the documented protocols and systems relating to the recording of repeat prescriptions, particularly where repeat prescriptions are requested by a Consultant or a Health Professional outside the Surgery. The review should consider the training of Health Professionals, including Doctors, and check systems to ensure that any request for repeat prescription is recorded and within the knowledge of a Doctor treating a patient. The review should also consider an alert, either in the Notes or on the computerised system, to any Doctor or Nurse Practitioner to check medications, particularly new repeat prescriptions at the next appointment. 3 Trequest the Chief Executive of the Wrightington, Wigan and Leigh NHS Foundation Trust conduct a review of policies, protocols and systems when a patient, particularly a vulnerable patient, self-discharges from the Hospital without necessary medications so that all Health Professionals, including Doctors, can be aware of the protocols if a patient self-discharges from the Hospital in circumstances similar to the deceased. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you 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 Friday 3 November 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- ee 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. Dated Signed (Yar Alan P Walsh, HM Area Coroner 8" September 2017
2 responses 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.
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Wrightington, Wigan and Leigh INHS| NHS Foundation Trust Legal Services Department Trust HO Royal Albert Edward tnfirmary Wigan Lane Wigan WN1 2NN Tel: 01942 822997/2172 ‘ax: 01942 822170 Email: ee] Web: www.wwi.nhs.uk Mr Alan Walsh HM Area Coroner Manchester West "HM Coroner's Office Paderborn House Howell Croft North Bolton BL1 1QY - “56 Getsber 2017. - ne cose rn rn Dear Mr Walsh Regulation 28 Response: Terence Ryan (Deceased) Thank you for your Regulation 28 report dated g" September 2017. I understand that an inquest relating to the death of Terence Ryan took place on 24" August 2017. I have been fuily advised of the circumstances relating to Mr Ryan’s death and have read your report. I am grateful to you for bringing these concerns to my attention. T would like to take this opportunity to respond to the issues raised in your report and to advise you of the actions already undertaken by Wrightington, Wigan and Leigh NHS Foundation Trust (“the Trust’) and the ongoing action in respect of this matter. Lam aware that you have the following concerns regarding the care provided to Mr Ryan: 14. The evidence at the Inquest revealed that Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the hospital, particularly where they may be receiving necessary medication in the form of anti-coagulation treatment, At the Inquest the Deceased was Identified as a vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, family or Social Services to pring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. . Chairman: Robert Armstrong Chief Executive: Andrew Foster CBE : f say T appreciate that, in light of these concerns you have requested that the Trust conduct a review of policies, procedures and protocols in relation to:- I, Patients, particularly a vulnerable patient, who self-discharges from the hospital without necessary medications so that all Health Professionals, including doctors, can be aware of the protocols if a patient self-discharges from the hospital in circumstances similar to the Deceased. Please can J assure you that the Trust does have a Policy for “Self-discharge Against Medical Advice”. Tenclose a copy of this policy for your information. This version of the Policy was approved in November 2014 and was in place at the time that Mr Ryan was treated at the Trust. Tam aware that on 10" November 2016 Mr Ryan self-discharged against medical advice and left the hospital without waiting for a discharge notice or his medication, When Mr Ryan had expressed a desire to self-discharge the doctor attended and tried to establish the reason for the desire to self- discharge. The doctor discussed the treatment and mobilisation plan with Mr Ryan and explained the need to stay in hospital, particularly in light of his history of DVT. Mr Ryan initially agreed to stay, however later the same day the doctor was informed that Mr Ryan had decided to leave against medical advice and had left without his medication. Following Mr Ryan's discharge on 10" November 2016 there Is "and no discharge letter was sent to his GP: The Trust acknowledges that this was not an aceeptable - standard of care and represented a failure to comply with the Trust’s own policy. The Policy for Self-Discharge Against Medical Advice states at paragraphs 44 and 4,5:- 44. Consultant/Clinical Team The Consultant or other clinicians in the team are responsible for: 44.1 Utilising this policy fo support and minimise ihe risks associa of any patient in their care against medical advice. 44,2 Establishing the reason the patient is wishing to take thelr own discharge and adaress any Issues that can be resolved. ; 4.4.3 Explaining to the patient the reasons/benerits for remaining in hospital and give the patient the relevant information in order for him/her to make an informed decision. 4,44 Being aware of any concerns expressed regarding a patients’ mental health and ensure a mental health assessment fas been carried out if issues such as sele-harm / harm to other has been identified. 4.45 Ensuring that all patients who self-discharge have a completed EPR discharge fetter sent to the patient's GP. ted with the self-discharge 4.5 Ward Manager/Senior Nurse/Nurse in Charge The Ward Manager/Senior Nurse/Nurse in charge has a responsibility to: 45.1 Utilise this policy to support and minimise the risks associated with the self-discharge . of any patient in their care against medical advice. 4.5.2 Immediately inform the consultant or another cliniclan in the team when a patient expresses a wish to self-discharge against medical advice. 4.5.3 Contact the site co-ordinator/manager out-of-hours when advice and/or information regarding self-discharge process is necessary. 4.5.4 Establish the reason for the patient wishing to take their own discharge and adaress any issues that can be resolved. no record of any contact with, theGP 4.5.5 In conjunction with the doctor explain the benefits of remaining in the hospital to the patient in order for the patient to make an informed decision. 45.6 Involve family and friends to try and dissuade the patient against taking his/her own discharge. This must only be done with the consent of the patient. 45,7 Pocument the details of the self-discharge process Is completed and filed in the patients’ medical records. ‘ 45.8 Inform their direct line manager as soon as possible that the patient has taken their own discharge. 4.5.9 Report this as an inddent via the Trust's DATIX: system. The doctor who reviewed Mr Ryan on 10 November 2016 did try to establish his reason for wanting to self-discharge to try to address any underlying concerns, he did explain to Mr Ryan the reasons/benefits for him staying in hospital and provide him with the relevant information to enable him to make an informed decision. He also explained the medical implications and associated risks to self-discharge against medical advice, thereby using the provisions of the self-discharge policy to an extent, to support and minimize the risks associated with the self-discharge of the patient against medical advice. However, I appreciate that neither the treating doctor nor the nurse were aware of the Trust’s policy _ and this is unacceptable. Given the lack of awareness of the policy, it may be that the necessary ~ “Consideration was not given to Mr Ryan’s status a6 a vulnerable patient: It ig also accepted that there: re was a failure to complete an EPR discharge letter and send this to Mr Ryan’s GP, as required under the self-discharge policy and in fact, as is required for all patients on discharge. The failure to comply with this policy is unacceptable and resulted in the provision of care below the expected standard. Bulletin T have been informed that a bulletin with the key requirements of the Policy for Self-Discharge Against Medical Advice has been prepared for both clinicians and for the nursing staff to heighten awareness of the policy and ensure compliance. This information has been and will be shared/communicated In the following ways: In respect of clinicians: e The requirements of the Trust’s policy for “Self-Discharge Against Medical Advice” was _ discussed at the Audit and Governance meeting on 18 October 2017. This meeting is attended by senior clinicians and heads of departments who then communicate this information back to staff. e The outcome of Mr Ryan's Inquest and the requirements of the Self-Discharge policy has been communicated at the Divisional Quarterly Executive Committee (DQEC) Meeting which is attended by senior clinicians. « The bulletins with the key requirements of the policy have been put on the agendas for all specialty meetings and sent to specialty governance leads for cascading to all consultants. « Anemail has been sent from WE Medical Director to all Consultants and Specialist Associate doctors across the Trust enclosing a copy of the self-discharge policy and the bulletin with the key requirements of the policy for dinicians, with a request that they communicate this information to all junior doctors within their specialty to confirm that all are aware of and are complying with the policy. « The policy will be discussed at the junior doctors’ induction training and a copy of the policy and the document highlighting the key requirements for clinicians is fo be emailed to all junior doctors via the medical staffing coordinator. In respect of nursing staff: e The self-discharge policy and the bulletin with the key requirements of the policy for nurses has been put on the agenda for the Senior Nurses meeting, this information will then be cascaded down to all nursing staff by the senior nurses. e iInadvance of this meeting an email has been sent to all the senior nurses across the Divisions attaching the policy and the bulletin with the key requirements for nurses to heighten awareness and compliance with the policy. e The Policy and the key requirements for nurses will be included in the 5 point communication form which is forwarded to all wards and departments and all nursing staff will be required to complete a “read and sign” document to ensure that they have read the requirements of the policy for what they are to do ifa patient wishes to take their own discharge. Both of these bulletins will also be included in the News Brief and Team Brief which Is communicated to all staff Trust wide. The News Brief is a weekly email sent to all staff, I am aware that there will be link to these bulletins In this email to enable staff to review the recommendations of the policy for __ Self: Discharge Against Medical Adv commilnicated by liné mariage incorporated into the Team Brief power point document and will be communicated to staff at monthly team meetings across the Trust to ensure awareness of and compliance with the requirements of the policy. . The Team Brief ts a monthly Self-Discharge Policy and Discharge Letters As you will be aware the Trust has now implemented a Hospital Information System (HIS) which Is an electronic patient records system. Discharge letters are generated electronically through this system. I have been informed that as part of the audit of this system, the Ward Manager will receive a daily list of the patients for whom a discharge summary has not been completed. This is a real time audit so action can be taken to rectify this issue Immediately and a discharge summary can be sent to the patient's GP as the patient is being discharged/shortly after their discharge from the hospital. In respect of the requirement for a discharge summary/letter, the HIS system does not distinguish between patients who have been discharged by a doctor and those who have taken their own discharge. As such, all patients will have a discharge letter sent to their GP and any failure or delay to provide this will be picked up by the Ward Manager and rectified. In addition, I believe that the Trust’s medical coders, who attach a code to each patient to help categorise patients to enable data to be collated, now assign a code to any patient who has self- discharged. At the end of each month an audit is conducted of the patients with a self-discharge code to check that a discharge letter has been sent to each patient's GP. For any patients without a discharge letter, the Division Is notified and a letter is sent to the patient’s GP urgently. I trust that these systems provide reassurance that a situation such as occurred in Mr Ryan’s case will not be repeated. 27 ref is at power point presentation which Is... taff at their monthly team meetings: The bulletins will be." "+ >. cee The HIS system is audited and work Is currently being undertaken to develop a more sophisticated audit system to assess the quality of the information recorded on HIS. As such the Trust is continually seeking to improve its systems to ensure the best care possible for its patients. Continued action As noted above several changes have already been put in place follo following actions will be taken:- e Information as to the requirements of the self-discharge policy will continue to be communicated to staff through the channels as outlined above to heighten awareness and ensure compliance with the policy. e Developrnent of the auditing of the HIS system to ensure that any failure to provide or a delay in in providing a discharge summary will be identified and rectified in real time. é “he above actions will be monitored via the Trust’s Quality and Safety Committee which is chaired by a Non-Executive Director and attended by several members of the Executive team, including the Medical Director and Director of Nursing. dt hope the above response Is a testament to how seriously the Trust considers the concerns raised by . ° MiRyan’s death-Tcan reassure You that WWL has and-will Gontintre to. learn léss6ng" from Mr Ryan's. an care and the Trust is constantly seeking to improve the service we offer to our patients. Please can I pass my sincere condolences to Mr Ryan’s family for their loss. If you have any comments or suggestions in relation to the proposed actions above, IT would be only too pleased to hear from you. Yours sincerely Lil Andrew Foster CBE Chief Executive wing Mr Ryan’s sad death and the
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