Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0026, written 26 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 | 26 Jan 2018 |
|---|---|
| Reference | 2018-0026 |
| Deceased | Joan Betteridge |
| Coroner | Karen Harold |
| Coroner area | Hampshire (Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths |
| Organisation named | Hampshire Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Alex Whitfield Chief Executive Hampshire Hospitals NHS Foundation Trust Royal Hampshire County Hospital, Ramsey Road Winchester, Hampshire, S022 5DG 2. Park & St Francis Surgery Hursley Road, Chandlers Ford, Eastleigh, HantsS053 2ZH 1 CORONER I am Karen Harrold, Assistant Coroner for the coroner area of Central Hampshire. 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. htt[!://www.legislation.gov.ukluk[!ga/2009/25/schedule/5 httg://www.legislation.gov.ukluksi/2013/1629/made 3 INVESTIGATION and INQUEST On 19th June 2017, the Senior Coroner, Grahame Short, commenced an investigation into the death of Joan Elizabeth Betteridge aged 88 years old. The investigation concluded at the end of the inquest on 13th December 2017. 1 recorded a Narrative Conclusion as follows: I Joan Elizabeth Betteridge had a history of falls including the 31st May 2017. She was admitted to the Royal Hampshire County Hospital in Winchester on 9th June 2017. An X-ray confirmed a displaced fractured neck of left femur requiring surgery namely cemented hemiarthroplasty which took place on 10th June. Mrs Betteridge remained stable for 50-55 minutes into the operation and 3 minutes after cement insertion she developed a slow heart rate which despite immediate treatment resulted in her death. The post mortem confirmed the cause of death was bone cement implantation syndrome, a recognised complication of this type of operation. The medical cause of death was recorded as: 1 a) Bone cement implantation syndrome; 2) lschaemic heart disease. 4 CIRCUMSTANCES OF THE DEATH Joan Betteridge was an 88 year old lady who lived independently with her husband in their privately owned apartment at Brendoncare Knightwood - the Mews. Mrs Betteridge had a diagnosis of Parkinson's disease and mild COPD which required her to use inhalers on a daily basis. The autopsy also noted ischaemic heart disease with severe coronary artery atheroma plus some mild ventricular hypertrophy and an old myocardial infarction. Her daughters told me that the Parkinson's meant she was often unsteady on her feet which caused her much frustration when she felt it limited her mobility. This meant that she had a history of falls. In the days leading up to her death, Mrs Betteridge suffered a series of falls for a variety of reasons. On 29 May 2017, she lost her balance and fell to the floor landing on her hip. She was taken to the Royal Hampshire County hospital (RHCH) by ambulance and was admitted overnight for observation. Although there was bruising over the left hip, an X-ray confirmed there was no fracture so she was released home on 30th May with pain relief medication. The hospital also arranged for a physiotherapist from the Enhanced Recovery Team to support her at home with a six week package of care. The following day on 31st May at 03:00 hrs Mrs Betteridge was found on the floor in the lounge at home having sustained a large wound on the back of her head. She could not recall how she fell or injured herself. Once again, she was taken to the same hospital by ambulance at 05:37 hrs and a further X-ray was taken at 08:45. During the inquest, I read from a report prepared by Dr Chan, the ED Clinical Director, and she confirmed that the X-ray was reviewed by a junior doctor in the ED at 09:00 and she detected no abnormality but also discussed her findings with the middle grade doctor on duty, who agreed the findings. Mrs Betteridge was discharged from the ED department after 3Yz hours and returned home. The following day she was assessed by an experienced physiotherapist who was concerned about the difficulties in weight bearing, the degree of pain experienced and degree of functional decline so he contacted the GP surgery to suggest re-admitting to hospital for further X-ray. The GP made a house call the same afternoon and after a clinical examination pain in the upper left leg and groin was noted which was aggravated by abduction of the hip but external and internal rotation was painless and there was no shortening of the leg, both classic signs of a possible fracture. The doctor therefore concluded that the picture did not suggest there was a fracture but indicated her intention to request a repeat X-ray and Co-codamol pain relief was prescribed. On 2 June there was another fall and she was seen by Dr Rickenbach of the Park Surgery due to mobility difficulties. On examination he noted that she was well and alert and able to stand unaided and transfer to a commode. He discussed the situation with the lead carer and family as he felt it was unlikely she would be accepted for admission given the previous history involving two recent admissions and two X-rays confirming no abnormalities were detected. As a result, he felt a move to a nursing home was a better option than back to hospital as the weekend was approachin~. This took place on 3 June but there was a further fall the same day and also on 41 June. By 6th June Mrs Betteridge had developed fluctuating levels of confusion so the nursing staff contacted Mrs Betteridge's GP surgery and requested a review as she still had persistent pain. This was refused as the nursing home was in a different catchment area. On 7th June the fluctuating episodes of confusion persisted and it was noted that despite regular analgesia for pain this was not working. visited again and was unhappy with the lack of progress and concerned about the continuing pain in , as he was the left hip. This prompted him talk to Mrs Betteridge's GP, concerned that another x-ray had not been progressed and it was needed to exclude a confirmed a further request for an X-ray was made fracture elsewhere. on 7 June. He also indicated that surgery records confirmed a request had also been made on 1 June but he could not exJ!Iain whatQroactive st~RS were taken to monitor 2 and ensure the request was chased up if there was an apparent delay. On 8th June Mrs Betteridge was temporarily registered with the Twyford surgery and visited following a request from one of the registered nurses due to increasing pain on mobility. The GP noted that Mrs Betteridge was comfortable sitting in a chair. He noted there was no tenderness to left leg, knee or ankle and no pain on flexion of hip or rotation or on compression of pelvis. The plan was to continue analgesia and increase if required. He also wanted to chase the details of the ED attendance and previous x-ray results as few details were known but also request a further X-ray at the hospital fracture clinic the next day. On 9/6/17 Mrs Betteridge was readmitted via ED and an x-ray revealed there was a displaced fractured neck of left femur which required surgery, namely left cemented hemiarthroplasty. Overnight there was another fall out of bed. Surgery went ahead as planned on 1 olh June following a surgical and anaesthetic review. During preparations she was observed as stable. Her blood pressure was regularly monitored and all the signs were that she was cardiovascularly stable so surgery started at 15:20. She remained stable with a good blood pressure for a period of about 50-55 minutes. The surgeon prepared to fill the femoral canal with cement and thumb pressure applied when the prosthetic stem was inserted. Whilst waiting for the cement to set, Mrs Betteridge arrested. As mentioned already, she remained stable until3 minutes after cement insertion when she developed bradycardia. A consultant anaesthetist and intensivist attended quickly (having been called from the adjacent ward) and sadly despite immediate treatment with appropriate medication she eventually reached the point where a decision was made not to continue with resuscitation efforts in view of likely poor outcome and poor prospects of CPR being successful. She was pronounced dead at 16:19. 1 , confirmed cause of death was due to bone cement The pathologist, implantation syndrome as the post mortem histology showed the presence of bone marrow emboli within the blood vessels of the lung. In addition he felt a contributory factor may have been played by his findings that there was evidence of ischaemic heart disease including some degree pf hypertrophy; an old myocardial infarction and narrowing of the coronary arteries. He confirmed that bone cement is an acrylic substance used to secure implants to bone or to fill joint cavity and that bone cement implantation syndrome is now well recognised as an established complication although there is no widely accepted definition of its cause. When it occurs it can range from a mild form like transient hypoxemia to a fatal form including death. The incidence of BCIS varies widely in the literature and fatalities have been rare. The cause and processes involve are not completely understood but various theories have been proposed including: • The release of substances out of the cement itself and entering into the blood circulation then travelling to heart of lungs; • Bone marrow also entering the blood and forming emboli which can travel to other organs such as the lungs and heart; • Or debris from washing out the canal again causing emboli in the heart or lungs; • Or it could be a combination of all three factors. He did confirm that the literature confirms that it is a rare complication and death only occurs in approximately 0.1-0.4% of cases. In Mrs Betteridge's case given her degree of heart disease she would not have had the reserve to cope. After Mrs Betteridge's death, a subsequent review of the X-ray taken on 31st May also confirmed that revealed there was, in fact, an undisplaced fracture. normally there is a safety net in place, where radiologists review x-rays after they have 3 been initially interpreted in the emergency department and that often this is after the discharge of the patient. These are usually reported within a couple of days. Those reports are then reviewed by the emergency medicine consultant. Where there is a missed fracture the consultant will contact the patient to advise them of the diagnosis. In some cases the treatment does not need to change but in more serious cases where the patient needs further treatment they are recalled. In this case that review was not completed until12 June- two days after Mrs Betteridge'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:- 1) Park & St Francis Surgeries to review the system used to request X-rays and potentially other basic tests. intended to request a repeat X-ray on 1 June but I heard evidence that nothing happened untH the physiotherapist queried progress with a different GP in the same surgery. This raises concerns either that the request was not made or if it was made then it was not progressed in a timely fashion. A further request was made on 7 June and took place on 9 June, two days later. 2) Trust to expore potential IT changes to automatically capture an Xray request made by an ED doctor. , Director of Surgical Services, that many I heard from changes have been made to date and some are still ongoing such as planned future audits. He also confirmed that when an acute patient like Mrs Betteridge is discharged from ED back home for coumminty care, the radiology review is the fall back system. Priority is given to ED and GP referrals and the reason there was a delay in this case from 31 May until12 June was that the request for a review was registered as an inpatient referral not an ED referral. Why that happened was not known but clearly Mrs Betteridge was never an inpatient on 31 May. 6 ACTION SHOULD BE TAKEN In 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 23rct March 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 family of Joan Elizabeth Betteridge. In addition, I have also sent it to: 1) , Medical Director Surgical Services 1 am also under a duty to send the Chief Coroner a copy of_your re~onse. 4 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 Date: 26'" January 2018 K~~ Ka~ As ant Coroner Central Hampshire 5
2 responses 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.
INHS| Hampshire Hospitals NHS Foundation Trust Management Offices Basingstoke and North Hampshire Hospital Aldermaston Road Basingstoke Hampshire RG24 9NA By e-mail only to: hampshirecoroners@hants.gov.uk 12 March 2018 Chief Coroner Coroner's Office Castle Hill Winchester $023 8UL Dear Sir Inquest in relation to the death of Mrs Joan Betteridge ' acknowledge receipt of the Prevention of Future Deaths Report dated 26 January 2018 (the “Report”), issued by the Assistant Coroner for Central Hampshire Ms Harrold to Hampshire Hospitals NHS Foundation Trust (the “Trust”), under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Firstly, on behalf of the Trust, | offer my condolences to the family of Mrs Betteridge, to whom | am very sorry for their loss. | note the two concerns raised by the Assistant Coroner in the Report, the second of which requires a response from the Trust and the other of which is to be responded to by Park & St Francis Surgerys. | set out below the concern which relates to the Trust, together with our response. “Trust to explore potential IT changes to automatically capture an Xray request made by an ED doctor” My understanding of the issue raised by the Assistant Coroner is that it relates to how the location of x-ray requests are recorded when made though the electronic reporting system ICE. There are two ways to make such requests: 1. ICE via the electronic patient record (ePR). The clinician will need to manually select a location for the request, for example the emergency department. This is because there is no default location. 2. Adesktop version of ICE. There is a default location set for desktop computers based on their physical location, for example the emergency department. At log-in, the clinician is prompted to check the default location and ensure the correct location is selected. Hampshire Hospitals NHS Foundation Trust includes Chairman: Elizabeth Padmore Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital Chief Executive: Alex Whitfield and Royal Hampshire County Hospital www.hampshirehospitals.nhs.uk A factual finding at the inquest was that the request for Mrs Betteridge’s hip x-ray on 31 May 2017 was incorrectly mapped ci. short stay in-patient ward next to the emergency department in Winchester). The request should have been mapped to the emergency department because this affected the timing of radiological review and reporting. The Assistant Coroner heard evidence at the inquest from Mr HR Director of Surgical Services, about some possible reasons as to how the incorrect request location might have come about. Subsequent investigation by MEE Chief Information Officer, has confirmed that the request for Mrs Betteridge’s x-ray on 31 May was made through a desktop version of ICE on a computer in the emergency departmet which had a default location o The default location on that computer has since been changed to the emergency department. | am pleased to confirm that the other computers in the emergency department that are used for accessing ICE were already set to the correct default location. Clinical Lead for Emergency Medicine, has also confirmed that the clinicians working in the emergency department have been educated on the importance of correctly recording the location of the requests, since this directly affects the timeframes for radiological review and reporting of images. lam confident that these changes will mitigate the risk of a similar incident occurring in the future. | trust that this provides assurance that the concerns raised by the Assistant Coroner have been investigated and promptly addressed by the Trust. Should there remain any further concerns, | would welcome the opportunity to address these for you. Yours faithfully [lire Wat fee Alex Whitfield Chief Executive
DR. S.P. CHAPLIN-ROGERS PARK SURGERY _ DR. M.A. RICKENBACH ST FRANCIS SURGERY HURSLEY ROAD DR. KATHRYN M. A. FOWLER PILGRIMS CLOSE CHANDLERS FORD DR. C.D. ARDEN VALLEY PARK EASTLEIGH DR. JULIA M. TERRY CHANDLERS FORD $053 2ZH DR. JAYNE L. O'CONNOR EASTLEIGH SO53 4ST DR. S.C. GLANVILLE Enq & Appts: 023 8025 2131 DR. JOANNA S. BIRMINGHAM Enq & Appts: 023 8025 2131 Fax: 023 8026 8342 Fax: 023 8026 8342 Please reply to: P| Our ref: MAR/JCN 501945 01-Mar-2018 (Dictated 28-2-18) Ms Karen Harrold age one The Assistant Coroner 4G MAR 7Dle Coroner's Office Castle Hill WINCHESTER S023 8UL Dear Ms Harrold Re: Mrs-Joan Betteridge dob: 16-May-1929 24 Knightwood Mews Shannon Way Chandlers Ford Eastleigh SO53 4TL Thank you for sending us the report on Mrs Joan Betteridge. I have discussed the concerns with the partners of Park & St Francis Surgeries, in particular wt_—_ You have suggested under Item 1 that Park & St Francis Surgeries should review the system used to request X-rays and potentially other basic tests. Firstly, Dr Fowler wishes to clarify the situation and enclosed is the computer record of the relevant X- ray; this is dated 1/6/2017 and was “_ printed following the home visit. During the home visit, to see and examine Mrs Betteridge instructed the care staff to use this X-ray form which was made available to them at the surgery the following day should the patient’s mobility remain a problem. This was recorded clearly in the notes. This was to be done to exclude fracture. FY has undertaken a review of the procedure for requesting an X-ray and has discussed this with the doctors and staff at the surgery. Printed X-ray forms could cause a possible delay if they were to be collected from the surgery or have the potential to be mislaid if left at the patient’s home or residential faculty. Now that we have recently been given access to electronic X-ray forms it has been decided that doctors are to send X-ray forms electronically to the hospital rather than printing the forms. We have reminded all doctors that instructions to residential care staff and nurses should continue to be recorded clearly in the patient’s notes, as well as communicated explicitly, in order to avoid confusion regarding the management plan at a later stage. ‘ We-remain concerned that the care staff did not pick up the X-ray form as anticipated and hope that the changes that have been made in our processes will provide a reminder if the patient does not attend for X-ray. Yours sincerely oC yA On behalf of Partners at Park & St Francis Surgeries
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