Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0037, written 25 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 | 25 Jan 2018 |
|---|---|
| Reference | 2018-0037 |
| Deceased | Sandra Miller |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Milestones Trust
THIS REPORT IS.BEING COPIED TO:
2. [EEE sister of the Deceased
3. Care Quality Commission
4. Chief Coroner
1 | CORONER
| am, Dr. Peter Harrowing, LLM, Assistant Coroner, for the coroner Area of Avon
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 27th June 2016 | commenced an investigation into the death of Ms. Sandra Miller age
55 years. The investigation concluded at the end of the inquest on 24th January 2018.
The conclusion was that the medical cause of death was
(a) Pneumonia; Il E. coli septicaemia due to a urinary tract infection. Heart failure.
The conclusion as to the death was: The Deceased died of pneumonia contributed to by
heart failure and E. coli septicaemia consequent upon a urinary tract infection.
CIRCUMSTANCES OF THE DEATH
The deceased suffered with Down's syndrome, Alzheimer’s disease, hypothyroidism,
type Il diabetes mellitus and she had an epigastric hernia. She had impaired swallowing
and on occasion suffered with aspiration pneumonia. .
In May 2015 she was discharged from hospital to reside at Mortimer House Nursing
Home, Bristol, which is owned and managed by the Milestone Trust. On discharge from
hospital she had a urinary catheter due to a voiding dysfunction. This voiding
dysfunction was considered to be related to her neurological condition. She was also -
iricontinent of faeces. At a Best Interests Meeting held on 20th August 2015 it was
determined that owing to Ms. Miller becoming distressed and agitated at the time when
her urinary catheter was changed it was agreed that she could be sedated for this
procedure. Removal of the catheter was considered but when removed on previous
occasions she had gone into urinary retention. Therefore it was planned to refer her to
the urologist for further advice.
She was seen on 15th September 2015 py Consultant Urological Surgeon.
Ms. Miller would become agitated and try to remove or pull at the urine bag. As a result it
_| had become practice at Mortimer House to remove the bag and tubing and allow the
open catheter to drain freely on to-a pad. in his letter of 30th September 2015 to the GP
and copied to Mortimer House {EEE oted that this practice meant that there was
an open system from the outside world to the bladder which would increase her risk of
infections and that this practice should not be continued. He recommended the use of a
flip-flow valve if a bag could not be used and if that, was not successful to consider a
suprapubic catheter. The GP in evidence stated that the GP records indicate the advice
given to the staff at the home was to try the flip-flow valve.
A copy of this letter was date stamped as being received at Mortimer House on 15th
October 2015. However, in evidence the Assistant Home Manager stated that letter had
not been seen by her or her colleagues and therefore the recommendations of
GEE were not acted upon. Consequently the practice of leaving the urinary catheter
on free drainage continued.
In evidence the Assistant Home Manager further stated that Ms. Miller, who was
incontinent of faeces, wore incontinence pads, and the open end of the catheter was
‘tucked inside’ this incontinent pad and the pad changed four times daily.. Therefore the
open end of the catheter was in contact with, or close to, any faeces.
On 15th June 2016 Ms. Miller became unwell and she was attended urgently by an
Emergency Care Practitioner from the out-of-hours GP service. He assessed her as
suffering with sepsis probably due to pneumonia or possibly a urinary tract infection. Ms.
Miller was admitted as an emergency by ambulance to Southmead Hospital, Bristol.
The Staff Nurse in the Emergency Department observed the catheter to not be
connected to a bag nor was a spigot fitted. In evidence the Staff Nurse stated the tip of
the catheter was dirty. On removing the catheter a large quantity of foul smelling, pus-
like urine drained from the bladder suggesting the catheter had been blocked.
Investigations revealed she was suffering with a respiratory and / or a urinary tract
infection and heart failure. She was treated for sepsis and blood cultures later revealed
she had an E.coli septicaemia.
Notwithstanding appropriate antibiotic therapy Ms. Miller’s condition declined and she
died in hospital on 21st June 2016. The primary cause of her death was considered to
be pneumonia.
At the Inquest the Area Manager of Milestones Trust, a registered nurse, who conducted
a review in advance of the Inquest could not confirm that action had been taken to stop
this practice of leaving a urinary catheter to free drainage; that proper procedures had
been implemented, and that staff had received any necessary training.
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) Urgent action must be taken to ensure the practice of allowing open ended urinary”
catheters to drain freely is stopped in all homes and facilities under the management
.and control of Milestones Trust. ,
(2). Proper procedures must introduced with regard to the safe care and management of
urinary catheters with the assistance of specialist advice if necessary.
(3) All relevant staff must be properly trained in the care and management of urinary
catheters.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your -
organisation has 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 22nd March 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.
8 | COPIES and PUBLICATION
‘| have sent a copy of my report to fd sister of the deceased, and the Care
Quality Commission.
| shall send a copy of your response to EES 'ster of the deceased, and the
Care Quality Commission.
| have sent a copy of my report to the Chief Coroner.
| 1am 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 |25th January 2018.
Assistant Coroner
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