Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0101, written 10 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Apr 2018 |
|---|---|
| Reference | 2018-0101 |
| Deceased | Lea Hunsley |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Community health care and emergency services 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Registered Manager, EAM Care Group/EAM House CORONER I am Ms L Hashmi, HM Area Coroner forthe Coroner area of Manchester North. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 1th8 July 2017 an investigation into the death of Miss Lea Louise Hunsley was commenced by HM Coroner Manchester City and thereafter, an inquest was opened. Subsequentlyjurisdiction was transferred, by agreement, to the coroner area ofManchester North. 4 CIRCUMSTANCES OF DEATH Against a backdrop ofcatastrophic birth injury (hypoxic ischaemic encephalopathy HIE), sustained during - the care ofand secondary to the management of her mother’s labour, Lea Hunsley (hereinafter referred to as Lea) had been diagnosed with profound Cerebral Palsy from around the time of her birth. Her complex healthcare needs included severe neurological impairment, resulting in significant effect upon her swallowing and putting her at risk ofchest infections and aspiration. As a consequence ofthis, Lea required a gastrostomy and thereaftersurgical intervention for oesophago-gastric dissociation (2015), in orderto reduce these risks and keep pace with her nutritional requirements. On the 4th July 2016, Lea went into respite care. For the early part of her stay, she was well and content. On the morning ofthe 9th July Lea was sleepierthan usual and when visited by her Grandparents, she gave sufficientcause for concern such that they sought the advice and opinion of the Registered Nurse (RN) on duty. The RN briefly examined Lea and took the view that all was well and in keeping with her general presentation. Upon further limited review laterthe same day, the RN’s view did not change. Medical assistance/review/escalation was not sought. During the course ofthe afternoon/evening ofthe 9th, Lea became increasingly unsettled and by 21:15 was showing the signs and symptoms of marked abdominal distension and was sweating and groaning. Her feed line was vented, to limited effect. By 21:30, her abdomen was distended again and a second venting was carried out. Carers called the duty RN as Lea remained ‘windy’ and unsettled. Again, a limited examination was conducted. No referral, escalation or medical assessment/review was sought. At22:45, Lea’s breathing pattern changed and she became very unwell. She subsequently went into cardio respiratory arrest. Cardiopulmonary resuscitation (CPR) was commenced and an ambulance was called at 23:12. When Paramedics arrived, they noted that Lea’s abdomen was significantly distended. On the balance of probabilities, the distention seen was not wholly attributable to the process of resuscitation. Lea was conveyed to the Emergency Department (ED) where advanced life support/resuscitation continued. Despite best efforts, Lea succumbed and died at the Wythenshawe Hospital Emergency Department at 00:10 hours on the 10th July 2016. There were a number of missed opportunities on the 9th July 2016, which more than minimally contributed to Lea’s death. The medical cause of death (after post mortem) was: la) Small intestinal perforation close to site of Roux en Y anastomosis required as part of gastro oesophageal dissociation ib) Severe feeding problems requiring surgical intervention Ic) Effects ofsevere hypoxic ischaemic encephalopathyfollowing asphyxia around the time of birth 2)— I reached a narrative conclusion: Died as a result ofthe rare but recognised complications of necessary medical intervention, resulting from a birth injury (HIE). Opportunities to assess, escalate and intervene were missed on the 9th July 2016 when it became apparent that there was a significant and sudden change in the deceased’s clinical presentation and condition. On the balance ofprobabilities, neglect more than minimally contributed to the deceased’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 reportto you. The MATTERS OF CONCERN are as follows: 1. EAM (a medicallnursing care facility) does not have a serious untoward incident (SUI) protocol. Responding appropriately when things go wrong in the healthcare setting is critical to improving patient/service user safety, identifying individual and systemic weaknesses, reducing avoidable harm and thus, preventing future deaths. 2. Registered Nursels and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the gth at all). 3. CQC Inspection insufficient action has been taken with regard to the recommendations made within the - last CQC inspection. During the course ofthe evidence heard at inquest, EAM accepted: i) that the most recent inspection report had found the home to be inadequate on safety and requiring improvement in all othercategories (effective, caring, responsive and well-led) ii) that meeting the recommendations had proved challenging but that the organisation was working with the CQC on improvements. However the Home did not demonstrate any marked or sustained improvement in any ofthe aforementioned areas of concern. This gives cause for concern in terms of the safety of other residents in EAM’s care, whether children or adults and the prevention ofserious harm/death. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the powerto take such action. 7 YOUR RESPONSE 5 You are under a duty to respond to this reportwithin 56 days of the date ofthis report, namely by the June 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 mustexplain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the ChiefCoroner and to the following Interested Persons namely: The deceased’s family - cuc - Central Manchester NHS Foundation Trust - NMC - I am also undera duty to send the Chief Coroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. 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. Date: 1th0 April 2018 SigdE..=-.
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.
EAM Cregroup Head Office: EAM Care Group Manchester Road, Partington Manchester, M31 4DJ Contact Telephone: 0161 777 8511 Email: Coroner’s Office H M Coroner’s Office The Phoenix Centre L CpI Stephen Shaw MC Way Heywood OLIO ILR 1st June 2018 Dear Ms L Hashmi Here is the response to the concerns raised within the Coroner’s Report: 1) No Serious Untoward Incident protocol in place at EAM 2) Registered Nurses and Carers at EAM: i. Lack the ability to identify, recognise and act upon the deteriorating patient ii. Did not escalate for medical review iii. Demonstrated a poor standard of basic (physiological) observation and monitoring iv. Failed to read and use the care records appropriately (in particular the RN did not read important/critical entries on the 9th at all) 3) CQC inspection- insufficient action has been taken with regard to the recommendations made within the last CQC inspection How we have addressed these concerns: Background 1 We met with Commissioners from Trafford Council, to complete a Root Cause Analysis. This was beneficial as the commissioning team were impartial and brought valuable experience, as they have undertaken similar exercises with other provider organisations. This helped with some of our actions. 2 It was identified that the information provided to support LH’s post operative care was insufficient and it compromised care. Therefore in 1 future we would obtain a post-operative care plan or information from the Consultant, following a multi-disciplinary meeting, ahead of any proposed stay in order that we may assess the support needs. If the risks associated exceeded our capabilities then we would not proceed with an admission, until the risks associated had sufficiently reduced. Any post-surgical admissions would include a post-operative care plan, prior to admission, to ensure that all staff involved in the young person’s care were adequately up to date in their support needs. We are currently developing deteriorating patient protocols specific to each young person’s care needs. These are to be in place in the next three months. 3 We will ensure that we put the young people first. To support staff in delivering this we have introduced restricted visiting times to ensure we are supporting young people with their health and well-being needs at key times. We have also introduced protected meal times. 4 We have introduced a Duty of Candour policy, which sets out our reporting of incidents to interested parties together with time frames. 5 We will ensure that we are included in any reviews, If reviews do not take place, at the instigation of the placing authority we will now hold our own review, annually, to ensure that we have a record of multi disciplinary reviews that steer us in supporting the revised needs of the young people in our care. We will respond to each of your concerns raised, which are as follows: 1) Serious Untoward Incident protocol • A Serious Untoward Incident Reporting Policy is now in place, together with a Duty of Candour policy. • Incidents were previously dealt with through investigations, however we have developed the above policy to add greater structure in our process. • If any family member, carer or professional had concerns we would now escalate to GP/Out of Hours service or Paramedic, even if the Registered Nurse’s observations show no concerns. • We have also changed our admissions policy for young people that have had surgery. We now require a post-operative multi-disciplinary meeting that sets out how to care for the young person going forward and the complications we could encounter. If the risk exceeds our capabilities then we would respectfully decline a young person’s stay, until our staff are adequately trained 2) i. Registered Nurses and Carers at EAM lack the ability to identify, recognise and act upon the deteriorating patient • We have person centred care plans which highlight all care needs and are updated at least six monthly or as care changes arise. These are done in collaboration with families and professionals involved in a young person’s care. • Staff have undertaken clinical observation training. • Nurse managers/seniors have received accredited train the trainer presentation skills course and have had training to deliver accredited clinical observations training ourselves. This will ensure it is delivered to staff at times that suit our needs, enabling more staff to access training. 2) ii. Registered Nurses and Carers at EAM did not escalate for medical review • There is now an updated When to Seek Medical Advice policy that staff have read and signed which advices when to seek medical help and to listen to family concerns. • Discussions are being held with our local GP practice in regards to one GP being assigned to EAM so there is more continuity from the GP practice. 2) iii. Registered Nurses and Carers at EAM demonstrated a poor standard of basic (physiological) observation and monitoring • All staff have now had formal training in clinical observations. Staff also receive basic resuscitation training which is additional to the clinical observation training. • Nurse Managers have received accredited training to undertake clinical observation training to deliver to all staff. This allows the training to be delivered at times that can include both staff on day shifts and those on night shifts • Hospital admission/discharge policy updated with ‘When to Seek Medical Advice’ now included in the policy. • 2) iiii. Registered Nurses and Carers at EAM failed to read and use the care records appropriately (in particular the RN did not read important/critical entries on the at all) • At the start of each shift, the nurse or senior who is running the shifts allocates each child/young person to a staff member. That staff member (or members, as they work in pairs) will be in charge of undertaking all care needs for the young person and completing any records for them. They will also verbally update the nurse/senior throughout the day of where they are up to. • Staff record notes at regular intervals during the day, for the young person they are allocated. This includes writing in their daily evaluations of all cares provided. • We have a new system for handovers which incorporates more thorough reading of the daily evaluation sheets written. Staff shift times have changed, to allow 30 minutes for handover, instead of the previous 15 minutes. Staff come in, and are asked to read at least the previous 48 hours of notes before handover. Staff then sign in the diary to confirm they have read and understood all the entries. This means that staff know what has happened with all young people, as well as receiving a handover of main events. This is now incorporated into the handover. • We have also introduced lunchtime handovers. After staff have had lunch, they now give handovers of where they are up to, what they still need to do, so that the nurse and carers remain up to date on what has happened up to that point. • Nurses and seniors who record entries in their note pads, for example phone call messages, conversations with families and professionals they may take, now have a hardback book and this will be archived so they can be retrieved if need be in the future. Previous practice had been to shred the paperwork at the end of the shift. Staff also aware if writing in retrospect to write the reason why and this has been incorporated into our Record keeping policy. 3) CQC inspection- insufficient action has been taken with regard to the recommendations made within the last CQC inspection • The CQC inspection in October 2017 was post LH stays at EAM. • Following the CQC report dated Oct 2017, EAM has completed an action plan which CQC is aware of as the Directors initiated a meeting with CQC. We have also had several meetings with Trafford Commissioners to ensure that we are working towards our actions. Our action plan is fully detailed to I demonstrate progress. Trafford Council’s Commissioning Team are working with EAM to ensure outcomes are within timescales. We have taken the Regulation 28 very seriously and have put into place what we feel would prevent a further death. I hope that what we have implemented offers reassurance that we have taken this very seriously. We understand that this is not the conclusion but the beginning of a revised and more structured working practice intended to protect all of the young people that we care for. Yours sincerely RGN, RSCN, MSc Child Studies, BSc (Hons) Children’s Community Specialist Practitioner, Founder/Director
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