Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0002, written 3 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jan 2018 |
|---|---|
| Reference | 2018-0002 |
| Deceased | Margaret Silver |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Margaret Jean Silver
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
Suzanne Rankin
Chief Executive
Ashford and St. Peter’s Hospitals NHS Foundation Trust
St. Peter’s Hospital
Guildford Road
Chertsey
Surrey
KT16 0PZ
1 CORONER
Ms Anna Crawford, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
An inquest into the death of Margaret Silver was opened on 4 March
2016. It was resumed on 28 November 2017 and concluded on 30
November 2017.
The medical cause of death was recorded as:
1a. Aspiration Pneumonia
1b. Fractured Left femur
II. Old Pulmonary Emboli, Frailty, Osteoporosis, Hypertensive Heart
Disease, Chronic Obstructive Pulmonary Disease.
The inquest concluded with a narrative conclusion, covering the matters
set out below.
4 CIRCUMSTANCES OF THE DEATH
Mrs Silver was an 85 year old lady who resided at West Hall Care Home
in West Byfleet.
On 12-15 November 2015 she was admitted to St Peter’s Hospital where
she was diagnosed with a deep vein thrombosis. As a result, she was
prescribed Rivaroxaban, (an anti-coagulant) for life. However, the
Discharge Summary contained contradictory information in relation to
the prescription, stating both that it should continue for 21 days and then
stop and also that it should continue for life. The inconsistency was not
noticed either by Mrs Silver’s GP or the staff at her care home, and as a
result, the Rivaroxaban was discontinued on 6 December 2015.
Mrs Silver attended St Peter’s Hospital on 1, 12 and 13 January 2016 and
on none of those occasions was the lack of Rivaroxaban identified or acted
upon by the hospital, despite Mrs Silver telling hospital staff on 12
January 2016 that she thought that she was no longer taking it.
Mrs Silver was then readmitted to St Peter’s Hospital from 26 January
2016 to 4 February 2016, at which point she was diagnosed with extensive
bilateral Pulmonary Emboli and restarted on Rivaroxaban. Prior to her
discharge on 3 February 2016, her mobility was noted to have decreased
and the Occupational Therapist recorded that she would require the use
of a commode on her return to the care home. It has not been possible to
establish whether or not this information was passed on to the care home.
On her return to the care home Mrs Silver presented with reduced
mobility and on both 5 and 6 February 2016 it is recorded that she
struggled to bear her own weight on being assisted to the toilet. However,
no changes to her care plan were introduced and she was not provided
with a commode. Information regarding her recent hospital admission
and reduced mobility was not passed on to the carers assisting her on 7
February 2016.
On 7 February 2016 Mrs Silver sustained an assisted fall whilst attempting
to transfer from the toilet to her wheelchair, sustaining a fractured left
femur. The court found that the fall resulted from her general frailty,
which was in part contributed to by the development of the pulmonary
emboli.
Following the fall she was readmitted to St Peter’s Hospital. She
developed a chest infection on 19 February 2016 and underwent surgery
on 22 February 2016. Her condition deteriorated and she died at the
hospital on 25 February 2016.
5 CORONER’S CONCERNS
The Discharge Summary contained contradictory information in relation
to the future prescription of inpatient medication, which led to the
medication being discontinued after 21 days when the intention was that
it be taken for life.
The fact that the Rivaroxaban had been discontinued was not identified
by clinicians at St Peter’s Hospital, despite Mrs Silver attending the
hospital on three occasions since her Rivaroxaban had been discontinued,
and despite her informing them on 12 January 2016 that she thought it
had been discontinued.
Mrs Silver was not provided with the equipment and support which had
been recommend by the Occupational Therapist prior to her discharge on
3 February 2016. It was not possible to establish whether the information
had in fact been passed on to the care home.
The MATTERS OF CONCERN are:
- Current procedures may result in inaccurate or contradictory
information about prescribed medication being included in
hospital discharge summaries.
- The procedures in place for recording a patient’s medication on
admission to, and discharge from, hospital may fail to identify
circumstances in which a patient is no longer in receipt of
potentially life-saving medication.
- The procedures in place for discharge planning may fail to ensure
that occupational therapists’ recommendations regarding
necessary support and equipment are not passed on to those caring
for patients in the community.
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1.
2. West Hall Care Home
3.
4. Care Quality Commission
5. The Chief Coroner
, Heathcot Medical Practice, Woking
In addition to this report, I am 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.
Signed:
ANNA CRAWFORD
DATED this 3rd Day of January 2018
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.
Ashford and St. Peter's Hospitals NHS Foundation Trust St Peter's Fospital Guildford Road Chertsey Surrey KT16 OPZ DX 119775, Chertsey 2 Tel 01932 872000 Web www.ashfordstpeters.nhs. uk Ms. A Crawford Text Relay prefix numbers with 18001 HM Assistant Coroner for the County of Surrey Station Approach Woking Surrey GU22 7AP 26th February 2018 Dear Ms. Crawford Re: Mrs. Margaret Silver Regulation 28 Report to Prevent Future Deaths Please find below my responses to your concerns raised following the inquest into the death of Mrs. Margaret Silver, 7. Current procedures may result in inaccurate or contradictory information about prescribed medication being included in hospital discharge summaries: The Trusts discharge letter template is to be amended to enhance safety associated with the generation and consequently improve end-user clarity regarding medications. Alll information pertaining to medications will be included in the same section on the discharge letter. An instruction note to be added to inform the Junior Doctors that all medication instructions should be confined to the medication section on the letter. The Trust intends to introduce electronic prescribing in 2019. This system utilises electronic systems to facilitate and enhance the communication of a prescription or medicine order, aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trail for the entire medicines use process. The benefits of ePrescribing for all users and all medicines-related tasks starts with the generation of a legible and complete medication order. This information can then be shared among multiple healthcare professionals, allowing reliable access to medicines information without having to hunt down a single paper record. Patients first « Personalresponsibility « Passion forexcellence ° Pride in our team Ashford and St. Peter's Hospitals NHS Foundation Trust 2. The procedures in place for recording a patient's medication on admission to, and discharge trom, hospital may fail to identify circumstances in which a patient is no longer in receipt of potentially life-saving medication: The Trust has commenced a pilot on the 12" February 2018 on new ways of working with nursing, residential and domiciliary care providers. Since March 2017 a multidisciplinary team of professionals from Ashford and St Peter’s NHS Foundation Trust and Adult Social Care have been working with a number of providers to identify better ways of working that will improve outcomes for individuals during and after their stay in hospital. All individuals that receive care from one of the pilot providers will be admitted to hospital with a red bag and a care passport. Inside their red bag will be their ‘My Care Passport’, medicines, medication documentation, personal belongings and essential items. The care passport will give professionals all the necessary information on the delivery of care for that individual, as well their interests, likes and dislikes. Each care passport will also be updated when the individual leaves hospital, so the provider can quickly understand if they need to be supported differently once they are back in the community. In addition to the red bag, we will be facilitating earlier and better communication and information sharing between the wards and the providers both before and after discharge to support the delivery of care once the person is back in their home setting. 3. The procedures in place for discharge planning may fail to ensure that occupational therapists' recommendations regarding necessary support and equipment are not passed on to those caring for patients in the community necessary support and equipment are not passed on to those caring for patients in the community: The ‘Red Bag’ process described above will improve the multidisciplinary communication between providers. Additionally there will be a section added to the discharge summary letter whereby Therapists can provide community providers with appropriate instructions regarding equipment required following discharge. | hope the details of the changes we have made to our practices are sufficient to allay the concerns you have raised in your report. Please do not hesitate to contact me should you require further details or documentation. Yours sincerely Suzanne Rankin Chief Executive Patients first = Personal responsibility ° Passionforexcellence « Pride in ourteam
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