Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0400, written 17 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 | 17 Nov 2017 |
|---|---|
| Reference | 2017-0400 |
| Deceased | Mildred Griffiths |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: St Giles Nursing Home CORONER tam Louise Hunt Senior Coroner for Birmingham and Solihull 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 09/08/2017 | commenced an investigation into the death of Mildred Joan Griffiths. The investigation concluded at the end of an inquest on 16th November 2017. The conclusion of the inquest was Natural causes. CIRCUMSTANCES OF THE DEATH The deceased fell from a chair at her home in May 2017 resulting in a fracture of her left distal femur, above a previous knee replacement. She was admitted to Birmingham Heartlands Hospital where she was noted to have a grade 2 sacral pressure sore. She was discharged to St Giles nursing home for care and rehabilitation on 02/06/17. She was largely bedbound and had poor nutrition and was unable to tolerate re positioning which caused the sore to deteriorate. Despite treatment she collapsed in the early hours of 03/08/17 and was declared deceased soon after arrival at hospital. Following a post mortem, the medical cause of death was determined to be: dia ISCHAEMIC HEART DISEASE 1b CORONARY ARTERY DISEASE 2 CARCINOMA OF LUNG WITH PNEUMONIA, PERFORATED DUODENAL ULCER WITH EARLY PERITONITIS, SACRAL PRESSURE SORE 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. The pressure sore risk tool used in the home is the Braden Score. The community Healthcare Trust use the Walsall score — which is nationally recognised. | note the Braden score does not take into account any existing lesion when calculating the risk which means it may under estimate the risk. In addition the Braden score calculates in an opposite way to the Walsall score —thus a low score is high risk in the Braden score, but low risk in the Walsall score. This can lead to confusion between professionals and the home should consider changing to the Walsall score. 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 4a" January 2018. |, 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:- Family and Birmingham Community Healthcare NHS Foundation Trust | 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 senda 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. 17/11/2017 Signature ( Louise Hunt Senior Coroner Birmingham and Solihull
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.
RECEIVED 12 JAN 2018 Avery Care With A Difference i3Y: 410" January 2018 Louise Hunt, Senior Coroner The Coroner's Court 50 Newton Street Birmingham B4 6NE Dear Ms Hunt, Reference: Regulation 28 Report from Birmingham and Solihull Coroner to Prevent Future Deaths relating to the death of Mildred Joan Griffiths which concluded the death was as the result of natural causes. | write in response to.your Regulation 28 report regarding the death of Mildred Joan Griffiths within which you raised a matter of concern regarding use of the Braden Pressure Ulcer Risk assessment tool at St Giles Nursing Home, Birmingham when the Community Healthcare Trust use the Walsall Tool. In responding to your concerns we have again reviewed the evidence available regarding the use of pressure ulcer risk tools and would make particular reference to documents from the National Institute for Health and Care Excellence (NICE). The role of NICE is to producing evidence-based guidance and advice for health, public health and social care practitioners, develop quality standards and performance metrics for those providing and commissioning health, public health and social care services and provide a range of information services for commissioners, practitioners and managers across the spectrum of health and social care. The documents of particular relevance are: e Pressure ulcers: prevention and management (CG179) . Evidence-based recommendations on the prevention and management of pressure ulcers. Clinical guideline. Published April 2014. e Pressure ulcers. Pathway of NICE evidence on preventing and managing pressure ulcers in all age groups in primary care and community settings in an interactive flowchart. NICE Pathway Published January 2012. Last updated November 2017 e Pressure ulcers (QS89). Evidence-based statements to deliver quality improvements in the prevention, assessment and management of pressure ulcers. Quality standard. Published June 2015 In summary with regard to pressure ulcer risk assessment NICE states “Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk” The two most commonly used pressure ulcer risk tools in the UK are Waterlow and Braden with no current evidence that either one is more effective at identifying risk than the other. The use of any risk tool should not outweigh clinical judgement and there are issues around sensitivity, specificity and also inter-rater reliability on all risk tools. 3 Cygnet Drive Swan Valley Northampton NN4 9BS - 5 : y t: 01604 675566 LaingBuisson % ER | e: enquiries@averyhealthcare.co.uk Q eres alCare www.averyhealthcare.co.uk O16 HealthInvestor ea Residential Awards 2016 care provider WINNER =fthe year 4 Larger Organlsatt? Company Registration Number: 08599361 P The Walsall tool is used locally by Birmingham Community Healthcare Trust and while we have found one small study related to recent validation of the tool published in 2000, this is limited. We also note that it was designed for use in the community and includes Carer Input as a category which is not appropriate for use in a care home environment. This tool has very limited use nationally and is specific to a local area. St Giles cares for patients from Solihull and other areas who do not use the Walsall tool either. We believe that this could also cause further confusion between professionals. We also note the following points: The resident who passed away on this occasion was unable to tolerate repositioning, and would frequently reposition herself on to her back, indicating this was where she was most comfortable and would also refuse repositioning. This would have lent itself to deterioration of the wound, regardless of the risk assessment tool being used. The resident moved into the home with a leg plaster cast in situ further decreasing her mobility and making repositioning difficult. The local Tissue Viability Nurse was supportive of the care and treatment which had been given by the team at St Giles Nursing Home, and was aware that degradation of the wound may occur owing to a lack of compliance with repositioning. At Avery Healthcare we pride ourselves on the low prevalence of home acquired pressure ulcers within our care homes. We care for over 3000 residents and have an average home acquired prevalence of less than 1.5%. This compares to national rates of between 4.7- 32.1% in hospitals and up to 22% in nursing homes (NICE). We use the Braden risk tool to support staff with assessing risk throughout England as it has had studies conducted specifically for the older age group, covers the main areas of risk and has in our experience (and for which there is weak evidence) better inter-rater reliability. The average prevalence rate for home acquired pressure ulcers at St Giles nursing home is 2.3% year to date and there have been several months this year where there have been no home acquired pressure ulcers in the home. We are confident that the risk tool which we use and the systems and staff training which we have in place are effective but have conducted a root cause analysis in this case to ensure that organisational learning can take place. Thus having reviewed your recommendation and the evidence we propose to continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards. Yours Sincerely (rallod . Sandra Stark Director of Care and Quality Avery Healthcare Group i H
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