Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0414, written 20 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 | 20 Nov 2017 |
|---|---|
| Reference | 2017-0414 |
| Deceased | Peter King |
| Coroner | Patricia Harding |
| Coroner area | Kent (Central & South East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Kent Hospitals University 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 THIS REPORT IS BEING SENT TO: East Kent Hospitals University NHS Foundation Trust CORONER 1 I am Patricia Harding Senior Coroner for Central and South East Kent 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 30/03/2017 I commenced an investigation into the death of Peter Blakeney KING. The investigation concluded at the end of the inquest 20th September 2017. The conclusion of the inquest was Peter King died on 19th March 2017 from head injuries sustained when he fell from his bed on 18th March 2017 whilst an inpatient at William Harvey Hospital where he had been admitted with confusion and fever. This, together with his age and mobility issues meant that Mr. King was a high risk of falls: at the time the fall occurred no precautions had been put in place to minimise the risk of falling 1a b c II Head Injuries 4 5 CIRCUMSTANCES OF THE DEATH Mr King presented to the Accident and Emergency department at William Harvey Hospital on 16th March 2017 with acute onset of confusion, headache, fever and limb weakness. He was treated with antibiotics for sepsis and a CT head was performed which was diagnostically of no use because Mr King was agitated at the time of the scan. Mr King was moved from the clinical decision unit to Cambridge M1 ward at 01.40 on 18th March 2017 and underwent a further CT scan at 09.08. He was sedated in order for the CT scan to be carried out. The scan showed no evidence of gross intra or extra axial collection or gross acute large infarction. At 18.50 on 18th March 2017 Mr. King was found sitting on the floor having fallen from his bed. The fall was unwitnessed by staff but another patient reported that he had seen Mr. King climbing through the gap between his bed rails and the end of the bed. Mr. King had not lost consciousness as a result of the fall but had suffered a bleeding laceration to his forehead which was dressed. It is not clear from the evidence how this injury was sustained. A CT scan performed at 21.41 revealed a large acute extra axial collection along the entire right hemisphere measuring a maximum depth of 33mm, a midline shift of 25mm and mass effect with compression and total effacement of the ipsilateral ventricular, third and fourth and frontal horn of the left lateral ventricle. There was a loss of grey-white matter differentiation and sulci/gyral pattern of the entire brain parenchyma. Acute haemorrhage appeared to be filling the fourth ventricle. Advice was sought from the neurosurgical team at King’s College Hospital who determined that Mr. King was not a candidate for any surgical intervention and should be conservatively managed as the prognosis was poor. Mr. King subsequently died on 19th March 2017. 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) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths. (2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall. (3) When Mr King was transferred to Cambridge ward from the clinical decision unit the receiving nurse recognised that Mr King should have been nursed in an observable bed with a crash mat and as neither were available on the ward, escalated the matter to the site co- ordinator. There was no evidence that these concerns were ever addressed by the site co- ordinator or followed up by nursing staff (4) A review of the falls risk assessment and bed rails assessment was recorded, however the fact that interventions were required to prevent the risk of falls was either not recognised or not implemented. (5) Falls risk was not addressed at handover 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you East Kent Hospitals University NHS Foundation Trust have the power to 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 16th 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; Next of Kin. I have also sent it to Care Quality Commission who may find it useful or of interest. 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 20/11/2017 Signature: Patricia Harding Senior Coroner Central and South East Kent
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.
REC!., 17 JAN 7018 7 East Kent Hospitals University NHS Foundation Trust Trust Offices Kent & Canterbury Hospitat Mrs P Harding ee Conseay Senior Coroner Central and South East Kent Kent CT1 3NG Cantium House 2" Floor Tel: 01227 866379 Sandling Road Maidstone ME14 1XD Our Ref: SA/HG/hp 12 January 2018 From: Susan Acott, Interim Chief Executive Dear Mrs Harding Re — Mr Peter Blakeney King (deceased) Following the conclusion of the Inquest hearing into the death of Mr Peter Blakeney King on 20 September 2017 and your subsequent letter dated 20 November 2017 pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, | write to inform you of the actions and considerations taken by East Kent Hospitals University NHS Foundation Trust. We note this Regulation 28 Report to prevent future deaths is one of three Inquests heard by the Central and South East Coroners in September 2017 and the matters of concern relate to the management of falls within the Trust. Acknowledgment by the Senior Coroner of the improvements that have already been made by the Trust regarding timely and adequate falls risk assessments is gratefully received and this work continues as outlined in my response. The rate of patient falls and patient falls resulting in harm to patients are key patient safety measures which the Trust monitors monthly as part of our quality indicators. They also form part of the core patient safety component of the Board priorities for 2017/18. Reports are received monthly to the Board of Directors and the Quality Committee on our performance against plan. We have set ourselves challenging stretch targets to achieve as our patient falls prevention programme is of a high priority. The latest confirmed results for October 2017 show the falls rate is 5.63 per 1,000 occupied bed days, which is below our target for the year. The confirmed falls national rate from the 2015 National Falls Audit was 6.6 per 1,000 occupied bed days; the Trust overall had a confirmed falls rate of 6.29 at the time of publication. This shows the falls rate for the Trust overall is better than the national rate. a The National Falls Audit also reports a patient harm rate i.e. where the harm to the patient, as a direct consequence of the fall is severe or death as with the patients concerned. The national rate in the 2015 report was 0.18 per 1000 occupied bed days; this was the rate for the Trust overall in this part of the National Falls Audit. This shows the rate of harm to be the same as the national rate. The results of the 2015 National Falls Audit showed that the Trust had improvements to make in all three of our bed-holding hospitals; this improvement programme has again been a priority for the Trust. There are no published studies of falls risk prediction tools that predicted risk at greater than 70% sensitivity. The National Institute Health and Care Excellence (NICE) therefore concluded that all inpatients aged 65 and older ‘should have their care managed as if they are at risk of falling’ on the basis that these patients ‘often have newly acquired risk factors (such as acute illness, delirium, cardiovascular disease, impaired mobility, medication or syncope syndrome) and are exposed to unfamiliar surroundings, which puts them at increased risk of falling during their inpatient stay’.’ The current falls policy and risk assessment tool reflect NICE guidance and we have focused on these areas specifically in order to action the factors that are known to reduce falls risk. We therefore reviewed our Falls Risk Assessment and Care Plan (FRACP) to be explicit about how incorporate this guidance. We also developed a quality improvement programme call “Fallstop” which to prevent patients falls in our care. Round 2 of the National Falls Audit took place in May 2017, after the three falls in question had occurred; the audit results were published on 22 November 2017, two days after the Trust received the three Regulation 28 reports. Table 1 demonstrates current performance and the improvements seen across the three hospitals. Table 1 - Comparative data from the 2015 and the 2017 National Falls Audit Site | Delirium | Continence! BP% | Medication | Vision % | Call bell | Mobility % CP % % % ald % 2017 oO 7 “K&CH 100 100 24 95 88 78 | «92 |QEQMH = 100 93 40 100 100 8 86 | WHH 92 93 / 38) 94 | 92. | 93 ~~ 100 | oO ; 2015 , | K&CH | 60 65.2 88.2 | 91.7— 667 | 846 | 92 |QEQMH | 65 50 667 8B 70.6 76.9 885 | WHH 37.9 45.5 45.8 0 36.4 18.2 | 556 | The patient falls all occurred on the frailty Ward at the William Harvey Hospital; this ward often has confused, wandering patients and this situation requires additional ‘eyes and ears’ to help provide a safe environment for the patients. It is a challenge to ensure that there are always sufficient staff on duty each shift to meet the ideal staff to patient ratio. Additional NHS Professionals Health Care Assistants and Registered Nurses that are requested are sometimes unfilled. Where this situation occurs, staff are redeployed from other clinical areas. We have in the past three month introduced SafeCare across the Trust. SafeCare enables ward staff see if their staffing levels match the demand and for staff to be moved across the site during each day. The nurse-in charge conducts a census three times per day of the number and acuity of the patients and inputs this onto the system. SafeCare then calculates the number of nursing hours that are required during this census period and compares it to the number of nursing hours available. This allows for the Clinical Site Team to make informed decisions when moving the staff to the area of greatest risk and allows for the efficient use of all available nursing time. In June, 2017 a business case was approved to support a full time band 4 Associate Practitioner (AP) for Falls Prevention and she joined the team in September 2017. She is actively supporting the Fallstop programme. | would like to take this opportunity of thanking you for your letter and can reassure you that we have taken on board your comments and will continue our commitment to deliver a safe and effective service to our patients. Yours sincerely Su fy Susan Acott Interim Chief Executive 1. National Institute for Health and Care Excellence. Falls in older people: assessing risk and prevention (CG161). Manchester: NICE, 2013. www.nice.org.uk/quidance/cg161 «t
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