Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0440, written 11 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jul 2017 |
|---|---|
| Reference | 2017-0440 |
| Deceased | Margery Astill |
| Coroner | Lydia Brown |
| Coroner area | Leicester (City & South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Leicestershire Partnership NHS Trust · University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Leicestershire Partnership ~ ~ ~~, ' ~_ ~d H s Tru$t Direct dial; Email: Our ref: MA/REG28/0817 16 August 2017 By email to Leicester.coroner(7leicester.gov.uk Lydia Brown Assistant Coroner Leicester City and. South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG Dear Mrs Brawn Re: Margery Astill A University Teaching Trust Corporate Affairs Room 170, Penn Lloyd building County Hall Leicester LE3 8TH Tel: 0116 295 1350 Fax: Q116 225 5233 www.leicsRart.nhs.uk Further to your report dated 11 July 2017, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, I offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of Margery Astill. Leicestershire Partnership NHS Trust takes these matters very seriously and I hope that you and Ms Astill's family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again. The matters of concern you have raised are as follows: Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion. Mental Health Services Older Persons (MMSOP) Ward Staff Teams have developed, and are in the process of implementing, a Standard Operating Procedure for the safe and effective management of the ward diary. Implementation is being led and embedded in daily practice by the Senior Inpatient Matrons and undertaken by each individual Ward Matron. The process also clearly defines how the ward tasks will be allocated and documented. This process will be subject to an ongoing monthly audit to provide assurance that this is being embedded in practice. MHSOP currently formally review all incidents weekly however there is a system in place for daily incident analysis which is supported by the Trust's Patient Safety Team that assures that the correct processes are being followed. Chair: Cathy Ellis Chief Executive: Dr Peter Miller MHSOP Ward Teams have also successfully piloted ward Safety Huddles and these are in place across Organic Wards as part of team working. Safety Huddles have been instrumental in supporting the ward teams in their shift by shift communication creating space to be able to dynamically assess the ward climate and talk about patient risk and incidents and how these are to be managed. As a further assurance measure the MHSOP wards are also being robustly supported with routinely designated safeguarding practice supervision sessions which look at, and analyse how, incidents have been managed and what has been teamed from this when in-patient harm. The previous installation of CCTV was to support the detection and prevention of crime. However within MHS4P it has been instrumental in bringing a new level of understanding incidents that occur on the wards. CCTV now forms a key part of the posf incident analysis process. As an additional assurance measure to ensure that the CCN is being used in this way, plans are in place to routinely undertake an audit of cross checking reported incident's and what parts of the CCTV recordings were reviewed to support the investigation process. 2. Communication with family members was inadequate and inaccurate, the „named nurse" system was Ineffecfive and therefore opportunities were lost to share information and fo keep the family informed and involved. The failure of the Trust fo engage with family members of patients with mental health issues have been raised in the past as a concern, and contrary to NICE Guidelines. The Trust acknowledges that the communication shared with the family following both the incidents was not an accurate description of the events which was later revealed in the CGTV footage. When the staff involved in the incidents provided Mrs Astill's family with information regarding her falls, their form of communication did not convey the accuracy of the situation. In order to enhance the nursing staff with their communication skills, the nurses involved have subsequently attended a bespoke training course delivered by LORDS (Leicester Hospice Charity). This training course supports enhanced communication skills needed to support patients and relatives. The service has approved the updated named nurse role and responsibility patient and carer information leaflet. Posters will be displayed on each ward defining the role of the named nurse to ensure that both patients and carers are clear about what to expect. A named nurse checklist has also been established to support Registered Nurses to carry out this role. This provides a clear accountability and audit trail whilst setting, standards around timely communication with relatives and carers. The Trust further acknowledges the Coroner's concern that it has not engaged with family members of patients with mental health issues which is contrary to Nice Guideline 13~'. With particular reference to mental health services for older ~ Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services (NICE Guideline, 136) Chair. Cathy Eris Chief Executive: Or Peter Miller people and inpatient admissions the service will be undertaking a spot check audit against the quality standard's as set out for hospital care. 3. Mrs AsfiU had two unwitnessed falls during her time in the unit, both were recorded on CCTV and both were due to interaEtian with other patients. The first fall was quickly attended by numerous nursing staff members, but there was a considerable delay in actually physically attending to the patient, examining her or taking basic observations. In a professional nursing environment this delay in first aid provision was of concern and the Trust should consider enhanced training to ensure immediate effective interventions. The Trust resuscitation lead has the responsibility for the Resuscitation Councils (UK) Basic Life Suppork and Immediate Life Suppork training. As part of their review they will analyse the CCTV footage to understand if there are any organisational changes required to the training, or if this is purely an individual training requirement. In addition to the above, I can confirm that the Trust Resuscitation Committee is overseeing the implementation of clinical drills. These drills re-enact patient emergency situations in the clinical setting in which staff on duty will participate in and will then be offered immediate practice reflection and feedback with regard to how they have responded to and managed this in practice. The MHSOP Clinical Education Lead is also scheduling in furkher experiential learning and practice development training opportunities to reflect on the immediate person centred approach to support emergency medical situa#ions. If I can be of any furkher assistance to you please do not hesitate to contact me. Yours sincerely, ~~ Dr Peter Miller Chief Executive Chair: Cathy Ellis Chief Executive: Dr Peter Miller
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr P. Miller, Chief Executive, Leicestershire Partnership NHS Trust. 1 CORONER am Lydia Brown, Assistant Coroner for Leicester (City and South) 2 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. 3 INVESTIGATION and INQUEST On 12/09/2016 I commenced an investigation into the death of Margery Annie Astill, 79. The investigation concluded at the end of the inquest on 09 June 2017. The conclusion of the inquest was Accidental death &attached sheet. Question 1a. Did Mrs Astill have a care plan during her admission, if not, should one have been put in place? Answer. No care plan but there should have been one as only had a community care plan. 1 b. Was there an effective "named nurse" system, and if not, should there have been? Answer. Insufficient evidence. 2. Was Mrs Astill assaulted by a patient on 29 August 2016, sustaining a head injury that required hospital treatment? Answer. Yes as seen on CCTV. 3. Should the safeguarding team and family of Mrs Astill have been informed on 30 August 2016 that she had been the victim of an assault? Answer. Yes. 4. Was the ward adequately staffed on 2 September 2016? Answer. No, ward had 5 staff instead of 6. 5. Were designated patient observation levels properly maintained on the afternoon of 2 September 2016? Answer. No as not all observations were completed. 6. Could any additional steps have been taken by the ward nursing staff or medical team to address the agitated patient's escalating behaviour of running around the ward do 2 September 2016? If so please set these out from the evidence available to you. Answer. Nothing more could have been done. , Cause of death: 1a Bronchopneumonia 1 b Traumatic axonal injury r 4 CIRCUMSTANCES OF THE DEATH On the 27th August 2016 the deceased had been admitted to the Evington Centre having been detained under Section 2 of the Mental Health Act. On the 2nd September 2016 the deceased .collided with another agitated patient who was running around the ward, causing her to fall to the ground in the Wakerley Ward corridor. She was taken to the Leicester Royal Infirmary on the same day, and diagnosed with unsurvivable head injuries. She died 3 days later on the 5th September 2016. 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) Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion. (2) Communication with family members was inadequate and inaccurate, the "named nurse" system was ineffective and therefore opportunities were lost to share information and to keep the family informed and involved. The failure of the Trust to engage with family members of patients with mental health issues have been raised in the past as a concern, and contrary to NICE Guidelines. (3) Mrs Astill had two unwitnessed falls during her time in the unit, both were recorded on CCTV and both were due to interaction with other patients. The first fall was quickly attended by numerous nursing staff members, but there was a considerable delay in actually physically attending to the patient, examining her or taking basic observations. In a professional nursing environment this delay in first ,aid provision was of concern and the Trust should consider enhanced training to ensure immediate effective interventions I. ACTION SHOULD BE TAKEN I n my opinion action should be taken to prevent future deaths and I believe you 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 Tuesday 5`h September 2017. 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 have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (son), (daughter). Mr J. Adler, Chief Executive, University Hospitals of Leicester NHS Trust. Sir David Behan, Chief Executive, Care and Quality Commission. 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 their lease or the publication of your response by the Chief Coroner. 9 [DATE] 11t"July 2017 B ONER]
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