Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0296, written 16 Oct 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 Oct 2017 |
|---|---|
| Reference | 2017-0296 |
| Deceased | Jeremy Marshall |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
DAVID W. G. RIDLEY Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Nerissa Vaughan Chief Executive Great Western Hospitals NHS Foundation Trust Great Western Hospital Marlborough Road Swindon SN3 6BB CORONER lam DAVID RIDLEY, Senior Coroner for Wiltshire and Swindon 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. http:/Avww.legislation,gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 24 November 2016 | commenced an investigation into the death of Jeremy Michael Holt Marshall and opened his Inquest on 27 February 2017 following receipt of the post mortem report. Dr Marshall was born on 18 August 1963 in Croydon, London and sadly died at The Great Western Hospital on 17 November 2016. He was 53 years old. | concluded Dr Marshall’s Inquest on Wednesday 11 October 2017 and recorded a cause of death as follows:- 1a) Small bowel obstruction and serosal tears 1b) Colonic adenocarcinoma (operated 31.10.2016) CIRCUMSTANCES OF THE DEATH Dr Marshall was diagnosed as having a colonic adenocarcinoma early Autumn 2016 and underwent an elective right hemicolectomy to remove the cancer which was carried out on 31 October 2016 at the Great Western Hospital. Dr Marshall's discharge was delayed due to an infection and slow progress but he was initially discharged on 09 November only to be readmitted a few days later on 12 November 2016. A CT scan subsequently carried out revealed that Dr Marshall had developed post operatively a small bowel obstruction and this was managed conservatively. Sadly Dr Marshall’s condition dramatically deteriorated on the night 14/15 November 2016 when at about midnight his NEWS score r was attended at that time by an as well as a Surgical reo ial a care plan was drawn up. the Ampney Ward Sister, bleeped the F1 doctor shortly before 0300 on the morning o lovember when Dr Marshall’s NEWS score reached 10 following a drop in his blood pressure and also_a drop in body temperature. He was attended to >Y ae! the Surgical F2 at the im alll = around about 0300 that il was noted that Dr Marshall was peripherally shut down. The care plan drawn up in particular jded for a review by the Medical Registrar as well as discussing with the Specialist Registrar ll The Site Manager, believes that the doctors left Dr Marshall’s bedside ut 40 minutes or so. Despite this it would seem that the General Registrar was not contacted until about 0430 that morning and it would appear that only contacted Dr Mukherji and bleeped him as a result of the intervention of the Site Manager who having spoken to Dr Payne, the General Registrar, advised that the Surgical Registrar needed to review Dr Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 Marshall urgently. This conversation took place at around 0500 between ii—iamimmmigind Dr and | saw evidence of both an attempt b' at 0513 followed by a bleep from the ward, presumably a ed at around 0530 and from then onwards steps were put in place for Dr Marshall to return to surgery. In the preparation for this inquest | had obviously site of the Root Cause Analysis secured by your hospital but | additionally also instructed 0 review the case. | should point out that | am very specific when | instruct an expert so as to ensure that they look at matters afresh. in this case was not provided with a copy of the Root Cause Analysis. concerns in relation to the delay in escalating Dr Marshall’ s case and was critical of assessment of the situation at ight on 14"” going into the 15"" November 2016. i HEE was of the opinion alll not realise as a result of that assessment the serious nature of Dr Marshall's deteriorating condition and in his view the matter should have been escalated at that time to an organisation such as the Critical Care Outreach Team although of course at the time Great Western Hospital were not operating a 24 hour system. | accepted the evidence of i: respect of his opinion in relation to the failings to escalate Dr Marshall’s case but one of the questions that | had put a to ascertain whether or not had the matter been escalated at midnight as to whether or not on a balance of probabilities, Dr Marshall would have survived. EEEEEFesponse to that question was that even at that stage on a balance of probabilities, Dr Marshall would not have survived even if the case had been escalated — he was that unwell. The subsequent surgery confirmed the bowel obstruction and also revealed significant adhesions that when tissue was separated gave rise to serosal tears were repaired at the time. Sadly Dr Marshall’s condition did not improve and in consultation with family, the painful decision was to withdraw life support and Dr Marshall died on 17 November 2016. Due to the fact that evidence was clear that even if Dr Marshall’s case had been escalated at around midnight on 14/15 November 2016 that more likely than not he would not have survived, case law prohibited me from recording and making determinations in relation to the failings on the Record of Inquest. That however does not preclude me from airing concerns in relation to Dr Marshall’s case with a view to the preventions of future deaths about which | will discuss in the next section. In concluding Dr Marshall's inquest | recorded a short form conclusion of Accident combined with a Narrative Conclusion as follows:- Accident and Narrative Conclusion: a: on 17 November 2016 at the Great Western Hospital, Marlborough oad, Swindon as a result of having developed complications (small bowel obstruction, adhesions and subsequent serosal tears) following an elective right hemicolectomy for a colonic adenocarcinoma which was carried out on the 31 October 2016.” CORONER’S CONCERNS During the course of the evidence the final witness | heard from was 0 was involved in the Root Cause Analysis. In respect of the following areas he indicated that he would take those observations by me back to the hospital. In law the only way | can ensure a response and given that | did not have explained to me how my concerns would be resolved with any certainty, | decided that | would make a Regulation 28 Report covering the following areas of concern:- 1. Expectations of F1/F2 doctors — personally | have no experience of training or being involved in the training of F1/F2 doctors and my only experience in respect of which | do not see a fundamental dissimilarity is in relation to trainee lawyers or in particular training solicitors in respect of whom | have been involved in their training during my professional career. F1/F2’s when appointed are given a provisional licence to practice at the end of their medical degree. Trainee solicitors are again allowed to work under supervision following the completion of their professional examinations which for example can be a degree combined with a post graduate legal practice course. My experience in relation to trainee solicitors is that t they realistically can do is at a low level and having heard fro’ formed the view that it is not fundamentally different in respect of F1/F2 doctors. The Great Western Hospital of course is a teaching hospital and therefore in relation to the training of doctors it is often, Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 l imagine, imperative that what may seem obvious to you or | perhaps needs to be spelled out to those trainees who may be entering the working environment in their chosen career area for the very first time. In relation to Dr Marshall’s case | was concerned that the evidence revealed that] had not contacted] unti he bleeped him at 0513 despite the care plan in relation to a seriously ill patient who at the time was peripherally shutting down in respect of which both had recognised the seriousness of the condition as to wh contacted sooner. There had been a3 point increase in his score yet there appeared to be a delay in conc ll to a degree and significant delay in conse No instruction had been given to nursing staff to bleep the relevant doctors and | am concerned as to whether or not in respect of all doctors that the point needs to be emphasised that whoever records the care plan on the notes at doctor level should have the responsibility of bleeping another clinician in a timely fashion unless the notes clearly indicate that that responsibility has been given to somebody else and then the notes to identify when and to whom that instruction was given. Review Point and fall back position when no further action is forthcoming <j Hand also care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill 2. cats that with the benefit of hindsight that such a timescale would have been desirable. | am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short, that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort the on call Consultant. | am satisfied and | have no doubt ina similar situation thot oc have no hesitation in making such a call but | am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan. Recording observations in a patient scoring 7 or above — | was comfortable hearing that a monitor was connected to Dr Marshall when his NEWS score reached 7 which would record observations electronically every 15 minutes and | heard evidence that at some point in 2018 you will be moving to an electronic system. In the interim | am concerned that there is no guidance given as regards the frequency of recording the observations on an Observations Chart in respect of a patient scoring 7 above on the NEWS score. Between 2350 on 14 November 2016 and 0240 on 15 November 2016 nothing was actually recorded on the Observations Chart itself which causes me concern in the interim. | did indicate to HE curing the course of the proceedings that | would like to come and visit once this system is in place and have a look for myself at the new software that you have in relation to NEWS scores and other new software that you have introduced in the last 18 months or so. | fully accept that there needs to be a balance as regards overburdening the nursing staff but at the same time | believe conversely that a gap of nearly 3 hours in respect of recorded observations of a critically ill patient is simply too long a gap. Should the frequency of observations be something again that should automatically form part of a care plan in respect of a critically ill patient? Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 11 December 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 | 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 October 2017 Signature Nw SS Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
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.
Great Western Hospitals INHS| NHS Foundation Trust Private and confidential The Great Western Hospital Mr David Ridley Marlborough Road Senior Coroner for Wiltshire and Swindon Swindon q SN3 6BB Wiltshire and Swindon Coroner's Office / , 26 Endless Street EE = Tel: 01793 60 40 20 Salisbury / VER Wiltshire = SP1 1DP Ss 15 December 2017 Dear Mr Ridley Re: Regulation 28 Report to prevent future deaths Dr Jeremy Michael Holt Marshall (deceased) Thank you for your letter of 18 October 2017 detailing recommendations for the Trust. This letter sets out the Trust’s response to your report. In your letter you have raised concerns with elements of the care provided to Dr Marshall. Although you found that these concerns did not contribute or cause the death of Dr Marshall, we acknowledge the possibility that left unaddressed, such concerns could cause problems for other patients in the future. The Trust takes all recommendations seriously. The Trust has reviewed our Root Cause Analysis investigation action plan and in light of your recommendations has updated this. | have enclosed a copy of this with this letter. | will also endeavour to set out a summary of what actions are planned to address your concerns. The prevention of future deaths report and recommendations has been discussed at executive level at the Patient Qualify Committee. Discussions have also been had at the preventing deteriorating patient's work stream which is one of the Trust’s quality initiatives. Expectations of F1 and F2 Doctors In your letter you expressed the view that junior doctors should be reminded that bleeping a colleague to escalate a patient is the responsibility of the individual doctor unless this task is specifically delegated. When the task is delegated the doctor should document in the care plan / patient notes to whom this has been delegated to. Our Values Service Teamwork Ambition Respect The Trust has considered your view and is of the belief there is no single solution to this. The omissions most likely stemmed from human factors rather than a systemic failing. Therefore a multidisciplinary approach is being taken strengthening personal accountability including updates to a handbook, simulation training and Adult Basic Life Support training. The next new intake of surgical junior doctors starts at the Trust on 6" December 2017. These doctors have access to an electronic handbook containing key information including standards expected in relation to delegation of duties. The handbook is a live document and will be under regular review. The Trust also has plans to update simulation training and the Adult Basic Life Support training. Simulation training consists of interactive training sessions relating to real life clinical situations. The Trust plans to incorporate the importance of clarity of communication (including delegating responsibility for tasks) into these sessions. Simulation training sessions which have already been held, have been found to be highly effective in developing the skills of staff. The Adult Basic Life Support is annua! mandatory face to face training for clinical staff. There is a plan to review the training provided and to update this to include scenario training on what to do in an emergency situation specifically in relation to the delegation of tasks. There is a plan to also include a section on what to do in a non-emergency situation and the importance of documenting delegation details. | would like to take this opportunity to inform you of other ways in which support is provided to the junior surgical doctors. e The speciality induction afternoon includes lectures on general surgical emergencies, ENT emergencies, urology emergencies, critical care outreach, and simulation session for the deteriorating patient. e Fortnightly MRCS (royal college of surgeons) training is provided, this is well attended e Monthly Junior doctor forum where quality improvement issues and other concerns can be discussed and raised Review point and fall-back position when no further action is forthcoming In the first part of this recommendation you suggested that for the higher acuity patient when a doctor reviews the patient they need a documented plan for follow-up. As with your previous recommendation, this will be included in the junior surgical doctor handbook. Other information included in the handbook includes clinical support and mentoring, work plans including ward rounds and guidance of specific tasks, core department guidelines and training opportunities. As you heard at the inquest into the death of Dr Marshall, the Trust has also developed new handover documentation for high risk surgical patients to ensure that patients are followed up appropriately. This includes patient name, location, diagnosis, bloods and other results and the treatment plan. Our Values Service Teamwork Ambition Respect In the second part of this recommendation you suggested that we ensure our nursing teams are confident and comfortable to escalate a situation to the on call consultant if critical care outreach is not available and no action is forthcoming from doctors. The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced. The Trust enables our nursing staff to be confident and comfortable in escalating to the on call consultant when required. As a contingency plan the Trust has an escalation process where the nurse escalates to manager/nurse in charge who would then escalate to matron or, if, out of hours to the clinical site manager. One aspect of the clinical site manager's role is to ensure timely escalation to consultants or medics in charge to highlight patient safety issues. These processes form part of the iRespond package which are available on all wards. Recording observations in a patient's NEWS is scoring 7 or more In your letter you felt there was no guidance regarding the frequency of documenting observations. The Trust has a ‘Recognition of the Deteriorating Patient’ policy and this mandates the requirements for measuring and recording of observations. The policy states that for a patient with a NEWS score of 7 or more, observations should be measured continuously and each set of observations recorded. As you heard at Dr Marshall's inquest, the Trust will be implementing electronic observations in the early part of 2018. In the meantime there is a quality improvement piece of work across the Trust to improve the recording and actions of NEWS. Audit data shows that the NEWS accuracy is consistently over 90%. In the New Year the Trust will be installing an electronic observations IT system. For this the Trust is developing clear algorithms to enable automatic escalation to the doctors, this will be on a loop so if for example the F2 doctors do not respond, this will be escalated to the registrars and will continue through the doctor ranks up to Consultant until someone responds to the escalation alert. | have enclosed the high level roll out plan, you will see we aim to have electronic observations implemented Trust wide by May 2018. The electronic observations system will improve the recording and accuracy of NEWS scoring and will reduce the risk of patients not being reviewed when they are unwell as escalation will be automated. Our Values Service Teamwork Ambition Respect In addition to the Trust's internal learning processes, our Medical Director requested that the Royal College of Surgeons complete a review of Dr Marshall's care, this is to ensure that all possible learning opportunities are explored. The Trust received the final report this week and will now review the report, consider the Royal College of Surgeons’ recommendations and develop an action plan to ensure the recommendations are acted upon, | hope that this provides you with assurance that the Trust are working to put measures into place and will continue to make improvements to try and ensure to safety of our patients. If you require any further information please do not hesitate to contact me. Yours sincerely [y- Nerissa Vaughan Chief Executive Encs — Updated action plan Electronic observation high level project plan Our Values Service Teamwork Ambition Respect
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