Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0352, written 30 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Nov 2017 |
|---|---|
| Reference | 2017-0352 |
| Deceased | Philip Powell |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Dudley Group NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, The Dudley Group NHS Foundation Trust. 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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 the 20 August 2017, I commenced an investigation into the death of Mr Philip John Powell. The investigation concluded at the end of the inquest on 30 November 2017. The conclusion of the inquest was a short narrative conclusion of: Mr Powell Died after developing sepsis when a pressure sore became infected and deteriorated rapidly from a grade 3 to grade 4. The cause of death was: 1a Sepsis and Bronchopneumonia 1b Infected Sacral Pressure Sore and Buttock Abscess 4 CIRCUMSTANCES OF THE DEATH i) Mr Powell was an 83 year old gentleman who had a medical history including Parkinson's disease, dementia and history of previous strokes. ii) He lived at home and was cared for by his family with support of Community nurses. iii) In July 2017 he started to develop an uncategorised stage 3 pressure ulcer and moisture lesion. iv) He was reviewed by a tissue viability nurse on the 18 July 2017 and Debrisoft which is anti-bacterial and used in the treatment of wounds wasn’t available at the time and the nurse placed a request for more supplies. v) No Debrisoft was in fact ordered. The pressure ulcer was then cleaned and dressed and managed with Flaminal Hydro and allevyn instead. vi) By the 4 August there were now clear signs of infection and the ulcer had become malodorous and inflamed. vii) By the 7 August the ulcer had deteriorated rapidly and he was admitted to Russells Hall Hospital where a 7cm cavity was identified and suspected 1 [IL1: PROTECT] sepsis. viii) Despite further treatment his condition continued to decline and sadly he died on the 16 August 2017 after developing sepsis and bronchopneumonia due to the infected pressure sore. 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 duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which would have helped in managing the wound. 2. In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action Although an internal investigation was completed, it did not address the issue of the delays in ordering Debrisoft and you may consider it is important to revisit this area to look at the systems in place. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 January 2018. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. 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. 9 30 November2017 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
Ref: Reg28/PJP/Jan18 Russells Hall Hospital
DUDLEY
West Midlands
DY1 2HQ
26 January 2018
Private and Confidential
Mr Zafar Siddique,
Senior Coroner
Black Country Coroner’s Court
Jack Judge House
Halesowen Street
Oldbury
West Midlands
B69 2AJ
Dear Mr Siddique,
Re: Response to Regulations 28 Report to Prevent Future Deaths – The late Mr Philip John Powell
I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest and your ruling on 30
November 2017, in respect of the late Philip John Powell. I should extend again the condolences of the Trust to Mr
Powell’s family.
The MATTERS OF CONCERN are as follows –
1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which may have helped in
managing the wound.
In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion
about the process and overall responsibility.
The important issues you raise have been taken very seriously within the Trust and I enclose an action plan which
confirms: a) the actions taken by the Trust in response to your concerns: b) the target dates for completion of those
actions; and c) the officers with responsibility for progress of the actions.
I trust the information provides assurances to you that the Trust has taken appropriate action to mitigate any further
patient safety issues with regards to timely procurement and availability of this product in future.
Yours faithfully,
Diane Wake
Chief Executive
Chairman: Jenni Ord Chief Executive: Diane Wake
Chief Executive:
Action not started/overdue
Action underway
Action completed
ACTION PLAN
Action Theme
Action
number
By
whom
Current progress
Status
Due Date
Assurances
Communication
1
Communication
2
Communication
3
Delays ordering
Debrisoft
4
(Deputy
Matron)
Meeting held 4 December
2017 with community
nursing senior leads - to
discuss the Coroner’s
Regulation 28 PFD report
Meeting held 20 December
2017 with Chief Nurse to
discuss Regulation 28 PFD
report
(Deputy
Matron)
Debrisoft management
pathway devised and
populated
In order to ensure there are
no delays Debrisoft is now
a stock item and ordered
through procurement.
community nurses have
stock items of Debrisoft (1
box of 5) in nursing bags at
all times
Meeting held on 21
January 2017 with the
CCG to discuss delays in
community nursing
prescription requests
Communication
5
(Matron)
Communication
6
Meeting held with the
Debrisoft Rep to discuss
the issues when raising a
prescription through the
GP surgery.
Matron)
04/12/2017
20/12/2017
20/01/2018
31/12/2017
21/01/2018
16/01/2018
Minutes of the
meeting can be
retrieved from the
0 Drive on the
shared drive
Completion of
Action Plan and
Debrisoft Pathway
Minutes of the
meeting –
Debrisoft Pathway
attached
The 5 localities
have placed
orders with
procurement.
Meeting held
22/01/18. CCG
gave assurance
that they would
discuss this
matter with lead
GPs
Debrisoft Rep is
liaising with GP
surgeries and
local pharmacies
in order to
cascade
educational
advice regarding
product and FP10.
Trust has follow
up meeting with
rep 06/02/18 to
ensure revised
processes are
working
Chairman: Jenni Ord Chief Executive: Diane Wake
Chief Executive:
Community Nursing process for the distribution of Debrisoft
Full Holistic Assessment - Debrisoft indicated
Refer to Debrisoft Lolly and Debrisoft user guide
August 2017
Debrisoft is now stock item
Equip all District nurse bags with a 1 box of 5
This is now mandatory
Nurse Prescriber
Use stock item and complete
prescription to replenish patient
supplies
Prescribers hold the responsibility
to ensure they have adequate
prescription pads
Non-Nurse Prescriber
Use stock items and order
prescription to replenish patient’s
supplies
Leave adequate supplies at patient
home for next visit
Fax prescription to GP surgery
Retain a copy of the fax report for audit
Administration support will collate this information and chase
receipt of the faxed prescription
Administration support to highlight to the Lead Nurse all of the
prescriptions which require confirmation of delivery.
Non-Nurse Prescribers and Nurse Prescribers are to ensure
that pharmacy has delivered to the patient within 72 hours
If patient has not received the prescription please continue to
use stock item
Community Nursing Team January 2018 v1
Chairman: Jenni Ord Chief Executive: Diane Wake
Chief Executive:
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