Francis Beech

Heart of England INHS

NHS Foundation Trust

Birmingham Heartlands Hospital
Bordesley Green East

Birmingham

B9 58S

| Tel: 0121 424 2000
Web: www. heartofengland.nhs.uk

31% January 2018

Mrs Louise Hunt

Senior Coroner for Birmingham and Solihull ,
50 Newton Street

Birmingham

Dear Mrs Hunt

Inquest into the death of Mr Francis Beech — Report to Prevent Future Deaths

| write in response to the Regulation 28 report made by you following your investigation and
inquest into the death of Mr Francis Beech on 12" December 2017, My sincere condolences
and sympathies are extended to Mr Beech’s family and friends on the sad loss of Mr Beech.

The Heart of England NHS Foundation Trust (the “Trust’) has carefully considered the
concerns raised within your Prevention of Future Deaths Report and has responded to each

of the seven points, as follows:
{

4. Lack of clear guidelines regarding the management of high risk fractures treated
conservatively

The Trust accepts that, at the time of Mr Beech’s death, there were no Trust guidelines in
existence regarding the management of potentially unstable fractures in frail patients that are
for conservative (non-operative) treatment.

Following the findings from this report, guidelines will be formulated for clinicians to follow for
these patients. These will include recommended timescales for follow-up and x-ray reviews
to be used in conjunction with clinical judgement. The new guidelines will be called
‘Conservative Management of Unstable Fractures’ and will be implemented by the Trust by
31 March 2018. Once the guideline has been implemented, the Directorate will audit

compliance. if you would like to see the guidelines, please let me know. |

The Clinical Director for Trauma and Orthopaedics has disseminated interim guidance to the
department whilst the guidelines are being developed.

Building healthier lives

Page 1 of 4
Interim Chair: Rt Hon Jacqui Smith — Interim Chief Executive: Dame Julie Moore

2. Lack of continuity of care. Each week a different consultant took over his care.
This led to a lack of continuity and inadequate discharge planning. ; ‘

Clear lines of accountability will be included within the guidelines mentioned above. The
admitting consultant will be responsible for formulating the initial management plan, which
can then be followed or modified, if clinically appropriate, by any Consultant or other clinician
who sees the patient as an inpatient or at a later outpatient appointment.

The consultant on-call rota is run on a weekly basis with changeover on Friday. Currently,
the exiting consultant completes a handover sheet for every patient, during his/her ward
round, which includes appropriate discharge planning. This is filed within the patient's notes.
It provides helpful information for the receiving consultant, such as original diagnosis,
management plan and any salient changes to the patients’ condition during his on call week.
Following this incident, a further point will be added on the handover asking for the date
when an X-Ray was performed and reviewed. This will emphasize the need for regular X-
Ray reviews as will be outlined in the new guidelines. Furthermore, there is a formal
handover which takes place every Friday between the exiting and incoming consultants.
The current process will be maintained but will be strengthened by the new guidelines. In
order to reinforce this, we propose to introduce a formal sign-off between incoming and
outgoing consultants to document that both parties are satisfied with the handover. '

It is appreciated by the Trust that the initial management pian to review Mr Beech within 6
weeks of discharge was inadequate. This was a matter of clinical judgment made at the time
and could have been changed by any subsequent consultant who had received handover for
the coming week. The new guideline will clarify the appropriate time for an outpatient
appointment following discharge for the management of a fracture such as Mr Beech’s.

3. Failing to arrange weekly x-rays after discharge to check for fracture alignment
and to monitor the fracture.

This matter has_been discussed with I Clinical Director for Trauma and
Orthopaedics. has confirmed that close follow up is required to identify
early displacement of fractures in patients undergoing conservative management. This
applies to potentially unstable fractures where surgical stabilisation has not been possible.
Once a patient is discharged, in the early stages of the fracture healing process, weekly
follow ups should be arranged to confirm that the position of the fracture remains adequate.
This would normally apply for a period of six weeks, at which point the position , of the
fracture is likely to have become more stable and is unlikely to displace any further.

Po has highlighted this case with all Trauma & Orthopaedic Consultants at the
Trust to highlight the importance of ensuring that a clear management plan and weekly x-
rays are arranged for patients not suitable for surgical stabilisation. It has been strongly
emphasised to all that this will be the responsibility of the consultant who made the initial
decision to treat the patient conservatively. The new guidelines will also be made available
for all clinicians to refer to.

Page 2 of 4

iy
4. Failing to arrange an outpatient appointment within 3 weeks of discharge

As per the above response to point 3 i :: reinforced the responsibilities to
all Trauma & Orthopaedic consultants employed at the Trust with regards to the correct
management for patients such as Mr Beech. In this case an outpatient appointment was not
arranged within 3 weeks as the management plan had specified that Mr Beech was to be
seen in 6 weeks. \

The Trust has taken steps to reduce the time that a patient will now experience when
awaiting an outpatient appointment for a consultant in Trauma & Orthopaedics. To support
patients being seen in outpatient appointments expeditiously the Trust has ordated 3 daily
“hot clinic” slots for post discharge follow-up. This will ensure that there is! capacity to
facilitate these reviews.

5. Failing to provide any information to the nursing home about the need to monitor
the plaster cast and that it was high risk : \

Mr Beech was discharged to St Giles Nursing Home as a “non-weight bearing patient”. On
review of the documentation that was handed over to St Giles, while the history and nature
of Mr Beech’s injury is clearly recorded, it is agreed that there was no patient-specific

(

handover that advised staff at St Giles to closely monitor the cast. {

Mr Beech was assessed by the Trust's Supported Integrated Discharge Team (SID) on 42%
June 2017. The purpose. of the assessment was to conduct a review of the patient's medical
needs (with access to the medical records) on discharge and to determine the suitability of
the home in question. St Giles will have received a copy of the SID assessment along with a
discharge checklist, Discharge to External Agency form, verbal handover and the electronic
discharge summary. Whilst the patient will receive a leaflet with advice on plaster casts at
the point when the cast is applied, the Trust accepts that it is inappropriate to expect that
patients, especially those in a confused state like Mr Beech, will pass the leaflet on to the
care home staff. In future, nursing staff will ensure that the literature on all plaster cast
management is included within the checklist of documents that are to be sent to the home
and not simply provided to the patient.

6. Failing to document pus on the cast when he attended on for a hip x-ray on :
01/07/17

The Trust does not challenge the findings that were reached at the inquest. The nursing and
medical staff who examined Mr Beech did not identify evidence of pus; however the Trust
acknowledges the WMAS handover document details this finding. The nurse cannot recall
whether WMAS staff verbally handed over their finding of pus on the cast.

Going forward, all of the staff involved in the care of Mr Beech have been reminded of the

importance of reviewing the full ambulance handover document which would have alerted
them to the ambulance crew’s full history and may have led to a more thorough assessment.

Page 3 of 4 ’ 1

in addition the ED and Trauma & Orthopaedic teams will be reminded of the potential risk of
breakdown of skin integrity and infection under plaster casts.

7. Failing to undertake an internal investigation to ensure lessons were learnt from
this case.

An independent review of the management of this case by the governance team is currently

being undertaken. . i

There are concerns regarding the. lack of reporting of this case by the ward staff, the way the
initial complaint from the family was responded to, and also the lack of appropriate
escalation to the Clinical and Professional Review of Incidents Group. This is a weekly
meeting chaired by the Executive Medical Director. The purpose of this group is to determine
the appropriate level of response to new incidents, either relating to potential lapses In care
or accusations of individual failings, and to provide oversight of the progress of any
processes initiated as a result.

The review will clarify these issues further and allow them to be appropriately addressed.
The review and subsequent action plan will be shared with you at a later date.

The Trust has taken the concerns raised within the Prevention of Future Deaths Report
seriously and confirms the details of this case have been raised at the highest levels within
the organisation. i

Yours sinc

emo

Dr David Rosser
Interim Executive Medical Director

Page 4 of 4

Avery

Care With A Difference

16" January 2018

Louise Hunt, Senior Coroner

The Coroner’s Court

50 Newton Street |
Birmingham

B4 6NE

Dear Ms Hunt,

Reference 120656: Regulation 28 from Birmingham and Solihull Coroner to Prevent Future Deaths
relating to the death of Francis Robert Beech.

| write in response to your Regulation 28 report regarding the death of Mr Francis Robert Beech who
was resident at St Giles Care Home in Solihull, Birmingham.

In response to your concerns | can confirm that we have implemented the following:

e Care of plaster cast policy and procedure
© Care of plaster cast care plan
e Supervision and training with staff on the safe management of residents with a plaster cast |
e Implementation of the National Early Warning score and process training in the nursing
homes

If you require any further information please do not hesitate to contact me.

Yours sincerely

4 Deyu ld)
a

Director of Operations
Avery Healthcare Group

Avery Healthcare Group

3 Cygnet Drive
Swan Valley
Northampton
NN4 9BS

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19 JAN 2018

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