Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0235, written 26 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 | 26 Sep 2017 |
|---|---|
| Reference | 2017-0235 |
| Deceased | Hedley Greenland |
| Coroner | Andrew Barkley |
| Coroner area | South Wales Central |
| Category | Care Home Health related deaths |
| 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.
ANNEX A 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. Tynant Nursing Home, Cymmer, Port Talbot 2. ABMU Health Board CORONER tam Andrew Barkley, Senior Coroner, for the coroner area of South Wales Central. 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. INVESTIGATION and INQUEST On the 11" January 2017 | commenced an investigation into the death of Hedley Greenland. The investigation concluded at the end of an inquest on 20" September 2017 and the conclusion of the inquest was that of a narrative conclusion:- “Hedley Greenland died from the effects of a urine infection in circumstances in which no adequate monitoring of his fluid input and catheter output took place for over 9 hours”. The medical cause of his death was recorded as 1a. E Coli septicaemia from urinary tract infection 2. Chronic kidney disease, frailty, old age, ischaemic heart disease. CIRCUMSTANCES OF THE DEATH The deceased was residing in the Tynant Nursing Home in Cymmer. He had a number of comobidities which included prostate cancer. As a result of the cancer he was permanently catheterised. Around the 14‘ December 2016 staff suspected he may be suffering with a urinary tract infection and his GP was consulted and a sample of urine sent for analysis. That indicated the presence of two “bugs” and the advice was to monitor his condition and if he were to show any signs of being systemically unwell further advice should be sought with a view to administering antibiotics. From the 14" December there was no sign that he was systemically unwell. The nurse on duty overnight on Friday 16" December was made aware of the position and the fact that he had not taken much fluid. She drained his catheter bag at 00.15am on Saturday 17! December and formed the view that he was dehydrated. She gave him additional fluids but noted that there was no further drainage from the catheter throughout the night until the end of her shift at 7.30 on the 17" December. Around 9.30 on the 17°" December it was noted that he had become acutely unwell and upon being re-catheterised approximately 600ml of purulent urine was drained from the catheter and it was suspected that he maybe septic and an ambulance was called. He was conveyed to hospital to the Princess of Wales Hospital where it was noted that he was bravely ill and his condition deteriorated and he passed away on the 20 December 2016. CORONER'S CONCERNS During the course of the inquest, and the investigation leading up to it, the evidence revealed matters giving rise to concern. !n my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland’s care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at teast 9 hours but probably substantially more than that. (2) The qualified nurse on duty overnight 16'/17"" December was not trained in male catherisation. (3) There was no evidence in the medical/nursing notes that the “Catheter Care Bundle” was being used. (4) The evidence given by two nurses involved in Mr Greenland’s care revealed a clear lack of understanding, knowledge and training as to how to manage a long term indwelling catheter. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21% November 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: 1) Chief Coroner 2) The family 3) Minister of Health Welsh Assembly Government 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. September 2017 SIG D: Mr Andfew Barkley> HM Senior Coroner
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.
7 G G Bwrdd lechyd Prifysgol Abertawe Bro Morgannwg ® F A University Health Board WALES Ein Cyf /Our Ref: ne? ABMU Health Board Dyddiad/Date: 18" October 2017 Headquarters One Talbot Gateway, Seaway Parade, Port Talbot SA12 7BR Mr A R Barkley Senior Coroner - South Wales Central Area, The Coroner's Office, 1° Floor, Rock Grounds, Aberdare, CF44 7AE Dear Mr Barkley, RE- INQUEST HEDLEY GREENLAND | write further to the Regulation 28 that you issued following the inquest held on the 20" September 2017 where the conclusion was a narrative. Abertawe Bro Morgannwg University Health Board provides a comprehensive training day in regard to urinary catheterisation for all Registered Health Care professionals employed by them. The Health Board also offers this training to registered nurses within the nursing home setting, however they are not obliged to attend. The Health Board encourages providers to nominate staff to attend the various training sessions offered, unfortunately the Health Board is reliant on the provider being able to release staff to attend. Since this incident a review has been undertaken. The Health Board have now implemented a booking and attendance system at community training which is to be recorded using an electronic central booking diary. This will ensure that accurate records are maintained of those who have attended training. It will also highlight areas where staff have not attended training. Furthermore, where training for catheterisation was shared previously between all Continence Assessors, the Community Continence Service will now take responsibility for training community staff and secondary care will train staff in the secondary care setting. « Chairman/Cadeirydd; Andrew Davies * Interim Chief Executive/Prif Welthredwr Dros Dro: Alexandra Howells ABM Headquariers/ Pencadlys ABM, One Talbot Gateway, Seaway Parade, Sagian Energy Park, Port Talbot. SA12 78R. Telephone: 01639 683344 Ffon 01639 683344 FAX: 01639 687675 and 01639 687676 REREhI.Tft > Bwrdd lechyd ABM yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg R FE Cc E IVE D ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board www.abm.wales.nhs.uk 25 OCT 2017 This will allow the Continence Service to structure training to the environment staff are working in. Training dates for catheterisation have been shared with Long Term Care Team to ensure the Health Board are able to monitor attendance from each care home. The Long Term Care Team work in partnership with Local Authority to monitor standards within the care home setting, part of this process is to review each care homes training register. Care homes that are not participating in training will be identified and monitored closely to improve compliance. The Health Board’s Nursing home assessors will receive training from the Community Continence Service regarding the management of urinary catheters including documentation. This will provide an opportunity for Health Board Nursing Home assessors to share good practice and to measure practice within the Care home setting against agreed standards of practice. Good practice documentation will be shared with the Long Term Care Team on the 31° October 2017 when the Community Continence Service and Long Term Care Team meet. This will include catheter bundies, patient urinary catheter passport for dissemination to Nursing/Care home staff. The care home sector are not currently using the above documentation in totality as the catheter passport is a new document which was recently introduced to the hospital & community setting and will now be extended to care homes. Long Term Care Team will explore the feasibility of setting up a network of ‘Continence Champions’ where additional training could be provided by the Community Continence Service to cascade in all homes. Due to the large number of care home staff in the region the Health Board can offer a general level of continence training to care home staff, however, Continence Champions will be provided with a more intense programme of training to ensure they can support and advise their colleagues. Additionally, a continence e-learning link will be shared with Long Term care team for dissemination to Nursing/Care home staff. Representative of Community Continence Service to attend the Care home providers meeting. All care homes in the region are represented in these meetings, the meeting allows care home managers and owners to receive updates and awareness sessions on relevant topics relating to health and social care. This is also an opportunity to share lessons learnt and good practice. | trust the above information addresses the matters of concern raised in the Regulation 28 report. Please do not hesitate to contact me if you require further information. Yours sincerely, Priscnrote HU ALEXANDRA HOWELLS INTERIM CHIEF EXECUTIVE
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