Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0378, written 19 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2017 |
|---|---|
| Reference | 2017-0378 |
| Deceased | Lindsey Parker |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Acute Hospitals NHS 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Salford Royal Hospital CORONER I am Ms L Hashmi, Area Coroner for the Coroner area of Manchester North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 2th0 July 2017 I commenced an investigation into the death of Mrs Lindsey Parker. This concluded, by way of inquest, on the 1t[8i December 2017. I reached a narrative conclusion, namely that the deceased died as a result of the rare but recognised complications of medical therapy (Naproxen). 4 CIRCUMSTANCES OF DEATH: I found: In mid-2016 Mrs Parker presented to her GP with a cyst-like swelling to her scalp. This was initially treated with antibiotics and she was listed for minor surgery at the Practice. On the 10th August the lump was removed and sent for histopathology. She returned to the surgery on the 24th August 2016 for suture removal by the Health Care Assistant. During the course of this appointment she saw her digital health record; it alluded to a diagnosis of cancer. She had not been formally advised by her doctor ofthe outcome ofthe histopathology result, received on the 23rd August, which confirmed a diagnosis of probable metastatic Adenocarcinoma (the scalp lesion believed to be a secondary tumour). Mrs Parker was referred to the hospital and underwent a number of tests and medical appointments with Physicians, Radiologists and Oncologists. A primary lung cancer was diagnosed with metastatic spread into scalp and eventually, the pancreas and liver. Whilst the cancer could not be cured, symptom management/treatment was instigated and steps were taken to establish whether Mrs Parker was appropriate for inclusion in clinical cancer trials. As part of her pain management regime, Mrs Parker was prescribed Naproxen. More likely than not, whilst originally having been prescribed by her GP, she did not receive a first dose of this medication until around the 28th April 2017 whilst a hospital inpatient. On the 21st June 2017 a skin rash started to appearon Mrs Parker’s neck and shoulders initially believed to - be due to sun exposure. However the rash continued to spread and blisters started to appear. She attended Accident and Emergency on the 23rd June and was immediately referred to the Dermatologist on call, who made differential diagnoses of Toxic Epidermal Necrolysis (TEN)/Stevens Johnson Syndrome (SJS). Mrs Parker was transferred to ICU but subsequently moved on to a Dermatology ward where topical therapies, symptom management, fluid replacement/fluid balance and antibiotic therapy (upon the advice of the Microbiologist) were instigated. There was liaison between the Dermatology and Oncology teams. TEN was subsequently confirmed by skin biopsy. An elevated CRP countwas attributed to inflammatory response. Up until the 7th July Mrs Parker’s condition remained guarded but stable. On the 8th July there was a marked deterioration in her overall condition. She became confused, agitated and her oxygen saturations fell. The doctor was notified at around 13:30. A medical review was to be conducted. This did not take place until 6-7 hours later. In the intervening period, staff did not adequately recognise or act upon ongoing deterioration, norwas there sufficient escalation when medical staffdid not appear. When a chest x-ray and further tests were conducted diagnoses of pneumonia and acute kidney injury were made. Mediation was revised. Consideration was given to transferring Mrs Parkerto the HDU, however this was not deemed to be in her best interests. She continued to succumb and died at the Salford Royal Hospital on the 9th July 2017, with the factof her death confirmed at 06:15. A review of care conducted by the Hospital Trust identified that fluid balance charts were not completed and observations were not taken/recorded, outwith expectation. Itwas not possible, on the evidence heard, to causally link the omissions identified to Mrs Parker’s death. 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:- Whilst I heard evidence from Matron regarding her (albeit limited) review of the circumstances surrounding Mrs Parker’s admission and from the Consultant involved in her care, I was not reassured by the steps taken to date, nor do I believe that they have been taken in a timely manner. No substantive action plan has been proffered. I remain concerned about the following: 1. A lack of continuity in medical care. According to the family’s evidence, Mrs Parker was seen by 16 different doctors during the course of her last admission. Ofthese, seven werejuniordoctors (FY grade). 2. Matron’s review identified gaps in basic nursing care vital signs/observations not recorded, potentially affecting the NEWS and inadequate fluid balance chart — completion. Both are critical to patient care and safety, particularly given Mrs Parker’s serious clinical diagnosis (TEN), against a backdrop of an already life limiting/threatening diagnosis. 3. Failure to adequately recognise the deteriorating patient and to act and/or escalate matters accordingly. 4. During the course of the evidence, Trust staff were unsure as to what qualifications the ‘Hospital at Night’ site co-ordinators held. They believed that most, if not all, were likely to be Nurses. My concern here is how/why nurses are deemed suitably qualified to manage out of hours medical prioritisation ofcare. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the powerto take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 113h February 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 reportto the Chief Coroner and to the following Interested Persons namely:- The deceased’s family - Pennine Acute Hospitals NHS Trust - Department of Health, London - Salford CCC - CQC - I am also undera duty to send the ChiefCoroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary from. 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 ChiefCoroner. Date: 1th9 December2017 Signed:
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.
CHIEF EXECUTIVE Sir David Dalton Northern Care Alliance NHS Group Telephone: E-mail: DND/JM 19 February 2018 STRICTLY PRIVATE AND CONFIDENTIAL Ms L Hashmi, HM Area Coronerforthe Coronerarea of Manchester North. Coroner’s Service Phoenix Centre L/CpI Stephen Shaw MC Way (formerly Church Street) Heywood OL1O iLL Dear Ms Hashmi Re: Mrs. Lindsey Parker (Deceased) Response to Regulation 28: Report to Prevent Future Deaths to Salford Royal NHS Foundation Trust. Please find below the response of Salford Royal NHS Foundation Trust following the inquest into the death of Mrs Lindsey Parker and the Regulation 28 Report which you issued on 19th December 2017. Your concerns were set out in the Regulation 28 Report as follows: 1. A lack ofcontinuity in medical care. According to the family’s evidence, Mrs Parker was seen by 16 different doctors during the course of her last admission. Of these, seven werejunior doctors (FYgrade). 2. Matron’s review identified gaps in basic nursing care vital signs/observations not — recorded, potentially affecting the NEWS and inadequate fluid balance chart completion. Both are critical to patient care and safety, particularly given Mrs Parker’s serious clinical diagnosis (TEN), againsta backdrop ofan alreadylife limiting/threatening diagnosis. 3. Failure to adequately recognise the deteriorating patient and to act and/or escalate matters accordingly. 4. During the course of the evidence, Trust staff were unsure as to what qualifications the ‘HospitalatNight’ site co-ordinators held. They believed thatmost, ifnot all, were likely to be Nurses. My concern here is how/why nurses are deemed suitably qualified to manage out ofhour’s medicalprioritisation ofcare. 3rd Floor Mayo Building, Stott Lane, Salford, M6 8HD Response of Salford Royal NHS Foundation Trust Continuity of medical care We are very sorry that the family raised concerns in relation to the number of clinicians who attended Mrs Parker during her admission. In order to assist the family, I can confirm that the following specialist clinicians attended upon Mrs Parker during her last admission: Consultant reviews Dermatology Mrs Parker was initially seen by (Ward Consultant) and (named Consultant). These specialist Consultant Dermatologists were on call when Mrs Parker was admitted. Mrs Parker was later seen by and who were on call over the weekend periods during Mrs Parker’s admission. Palliative Care Mrs Parker was also seen by a specialist Palliative Care Consultant, . Registrar reviews Dermatology When Mrs Parker was initially admitted Dr Sharif was on call. Mrs Parker was also seen by and at the weekend and as on call cover and , , who attended as the Registrar covering the ward on those days. Ophthalmology Mrs Parker was seen by who is a speciality trainee in Ophthalmology Medicine Mrs Parker was seen by three Medical Registrars between 2th4 June 2017 and 9th July 2017 for medical review, as part of the Trust’s escalation policy following deterioration in her medical condition and a raised NEWS score. Junior Doctors During this admission period Mrs Parker would have been seen by three Junior Doctors who were assigned to ward M3. These were: (GPST1), FY2) and (GPST2). As described above I would like to reassure Mrs Parker family that she was seen by a total of three Junior Doctors and not seven. I do sincerely apologise that Mrs Parker family felt that she was seen by a number of different Junior Doctors and that this was not clear during the course of the evidence. Unfortunately, Mrs Parker was seen by a number of different clinicians due to varying shift patterns, on call out of hours care and because Mrs Parker required the input of various different specialities. Nevertheless it should have been explained to Mrs Parker family why there was a need for all the various medical input. I do hope the above 3rd Floor Mayo Building, Stott Lane, Salford, M6 8HD explanation provides Mrs Parker family with the rationale behind the multiple medical interventions from different clinicians. Different clinicians do work during the week and at weekends; and this is within normal practice. Please be assured a full handover would have taken place between clinicians, during this time. It is necessary both medically in the patient’s best interests to have clinicians from different specialities see and/or assess a patient during their admission. Compliance with adult observation physiological monitoring policy NEWS scoring NEWS was introduced to Salford Royal in November 2014, using a bespoke system that allows direct entry of vital signs into the patient’s electronic health record. All patients except those receiving terminal care and those in Critical Care wards have their vital signs entered into the Trust Electronic Patient Record (EPR) at a frequency that is determined by the care needs of the patient. Vital signs are entered at the bedside using a hand-held device (iPAD) and the Vital Signs can then be displayed in the EPR using the Clinical Summary display to show graphs or numbers. The electronic system calculates the National Early Warning Score (NEWS score) for each set of observations unless the observation set is incomplete. The NEWS score determines the frequency of clinical observation recording as follows: 0-2 3-4 5-6 >7 Patient stable Patient potential to Patient deteriorating Patient deteriorate Acute/critically ill Normal Extra vigilance Access and alert Senior medical observations Minimum 4 hourly Minimum 2 hourly review Minimum 8 hourly Minimum 1 hourly If the score is 5 6 an appropriate and timely clinical review should be undertaken by an - Advanced Nurse Practitioner (ANP), Foundation Doctor, or middle grade /core trainee. For scores greater than 7 a timely senior medical review, Registrar (SPR) and/or Consultant) must also be undertaken as happened above. — If a patient scores 3 directly upon 1 parameter (i.e. respiratory rate alone) or there is any other concern then medical advice should be sought in any event. Whilst the NEWS system at Salford Royal is effective, in the case of Mrs Parker there were occasions were the NEWS scores not completed and for this we sincerely apologise. Sadly, Mrs Parker did decline intervention on occasion and this meant that some of her observations were not completed. Mrs Parker was assessed as having capacity to make decisions; therefore, could not insist that the necessary observations were taken. 3rd Floor Mayo Building, Stott Lane, Salford, M6 8HD Fluid Balance Mrs Parker was having her fluid balance monitored (fluid intake measured against urine output to ensure hydration). Patients with the condition TEN can lose high amounts of fluid through their skin and it is essential to monitor the urine output as this will indicate if a patient is becoming dehydrated. Mrs Parker was having her urine output measured hourly and the overall daily balance would have been calculated at midnight. On two occasions the urine output was not charted hourly. This is below the expected standard and the individuals have reflected upon their practice and learned from this event. The Ward Matron has also discussed the learning with the ward team and made changes to the content of the daily ward safety huddle to acknowledge which patients are requiring hourly urine output monitoring. To provide assurance that this standard is maintained a Senior Nurse conducts a weekly audit offluid balance charts. Recognition and response to deteriorating patient On review, although Mrs Parker’s clinical observations were escalated initially for review by the FYi and Dermatology Registrar, the nursing staff should have persisted to escalate them when Mrs Parker began to deteriorate. Again, this has been discussed with the staff involved for their individual learning and concerns regarding a response to deteriorating NEWS has been added to the ward safety huddle. Further monitoring is in place to ensure that elevated NEWS scores are escalated appropriately and within the timeframe stated in the adult observation policy via a weekly audit of the process. As a result of Mrs Parker’s case the staff have developed a visual aid to support the completion of timely clinical observations in a busy ward environment. The functioning, operational and clinical management of the hospital out of hours Salford Royal NHS Foundation Trust adopts the Hospital at Night’ model. This is a clinically driven and patient focused model, which uses both a multi-professional and multispecialty approach to delivering care at night and out of hours. The programme enhances patient safety and outcomes, and supports medical training and service delivery. The Hospital at Night concept proposes that the way to achieve safe clinical care is to have one or more multi-professional teams who have the full range of skills and competences to meet the immediate needs of patients. Salford Royal NHS Foundation Trust has successfully operated an out of hours triage system since 2006. Ward staff who have concerns about a patient, either triggered by a raised early warning score as a result of altered physiological results or other clinical concerns; such as uncontrolled pain, new onset acute confusion will submit an electronic referral. This referral is triaged within minutes by a senior experienced registered nurse who acts as the site coordinator. The site coordinator works within recognised parameters and frameworks. The calls are categorised as: Red urgent requires a response within 30 minutes Amber semi urgent requires a response within 1 hour Green routine work requires a response within 1-2 hours 3rd Floor Mayo Building, Stott Lane, Salford, M6 8HD These calls are allocated to the most appropriate member of the onsite team, who may be a Doctor. The most senior Doctor on site would be a Registrar grade supported by junior Doctors, Advanced Nurse Practitioners and Healthcare Support Workers. There are a number of on call speciality consultants available for advice or attendance when required. The Advanced Practitionerwork force is made up of registered experienced nurses, with master’s degrees in advanced clinical practice. They are staff working at the top of their professional license and within their scope of practice. They can clinically assess, diagnose, treat patients and are non-medical perscriber’s and form an essential and valuable part of the healthcare workforce. I hope that this response provides assurance to yourself and Mrs Parker’s family that Salford Royal NHS Foundation Trust has worked hard to ensure lessons have been learned in this case and improvements have been made. Please do not hesitate to contact me if you require any further information in relation to our response. Yours sincerely Sir David Dalton Chief Executive References The Case for Hospital at Night The Search for Evidence Department of Health The - - implementation and impact ofHospital at Nightpilotprojects: An evaluation report. (2005) 3rd Floor Mayo Building, Stott Lane, Salford, MG 8HD
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