Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0132, written 28 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 | 28 Apr 2018 |
|---|---|
| Reference | 2018-0132 |
| Deceased | Catherine Burns |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| 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)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Acting Chief Executive
Blackpool Teaching Hospitals NHS Foundation Trust
Blackpool Victoria Hospital
Whinney Heys Rd
Blackpool
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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.
3
INVESTIGATION and INQUEST
On 25th April 2018 I concluded an inquest into the death of Catherine Burns, born
03/05/41 and who was reported to have died at Blackpool Victoria Hospital on 05/12/17.
The inquest concluded was: NATURAL CAUSES
The medical cause of death was: 1 a LOBAR PNEUMONIA
4
CIRCUMSTANCES OF THE DEATH
Within box 3 of the Record of Inquest the circumstances surrounding this death were
summarised as follows:
Catherine Burns was admitted to hospital on 4th December 2017 complaining of
abdominal pain and at 20.09 hours was triaged as requiring to be seen by a doctor
within a period of ten minutes. She was first seen by a doctor no earlier than 1am on
5th December 2017 when it was felt that she was suffering from acute cholecystitis and
prescribed intravenous antibiotics which were administered. Initially stable Catherine’s
condition deteriorated at approximately 10.30 hours later that morning and by 12.50
hours she was observed to be having significant breathing difficulties. She went into
respiratory arrest at 13.45 hours and her death was confirmed at 13.48 hours. A
subsequent post mortem examination confirmed she had died from the effects of lobar
pneumonia which had developed prior to hospital admission.
In more detail:
This death occurred on 5th December 2017. The Deceased was triaged as requiring an
assessment by a doctor within ten minutes but was not seen by a doctor for at least
approximately five hours.
Although it could not be established that the outcome for her would have been
different there is no doubt that the care afforded to her during the hospital admission
was affected by the pressure which staff were expected to cope with.
The primary reason why she was not seen by a doctor for such a period was due to the
number of patients the staff in the Emergency Department had to deal with. I heard
evidence from a Year 1 Speciality Trainee working in the Accident & Emergency
department who was the doctor who first saw the patient and in his statement to this
court he had commented that “During busy periods, such as this night, there are
numerous patients triaged on red, orange, yellow and green throughout the
department, it is agreed that patients are seen in time order unless there are specific
concerns whereby a doctor, usually a Senior, will be asked to see a patient out of time
order. No specific concerns were raised about Mrs Burns prior to her being seen by
myself”.
However I also received evidence from a Consultant Colorectal & General Surgeon who
had been asked to provide an overview of the care afforded within the Emergency
Department and he felt that despite the above he would ordinarily expect that even
when it may not be possible for a doctor to assess a patient in accordance with the
triage assessment [so within ten minutes for Mrs Burns] in which case the patient
ought to be seen by a member of the nursing staff then the patient should be seen by a
doctor within a 30 minute period and he acknowledged that the working conditions
were behind the delay in this patient being assessed although he did not feel that any
delay ultimately affected the outcome for Mrs Burns.
After consultation with the surgical team a decision was taken that she be moved to
the Assessment Unit but a bed was not available and she remained in the emergency
department.
During the morning of the 5th December from 10.30 through to 12.50 there was
deterioration in her condition. By 12.50 hours Mrs Burns had deteriorated significantly.
Her Daughter alerted the nursing staff. The Consultant on Call for the Emergency
Department was alerted, realised the seriousness of her condition, but she arrested
shortly afterwards. In my judgement the seriousness of her condition had not been
fully appreciated at a time when the staff was so busy.
As it transpired an independent pathologist reported that Mrs Burns died from lobar
pneumonia which I found had developed prior to hospital admission. Indeed I found
that Mrs Burns was likely to succumb to the effects of the pneumonia by the time she
was triaged at the hospital.
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:
I am concerned that staff were unable to provide the level of care to Catherine Burns
that they would have liked to provide or which they felt was appropriate and that that
this was due to the number of patients they were expected to care for. Consequently
deterioration in her condition was not appreciated as quickly as it may otherwise have
been.
I am concerned that even during an extremely busy shift for a patient to be triaged as
requiring assessment by a doctor and for that patient to then not be seen by a patient
for over five hours risks future deaths and especially if the nursing staff are not able to
monitor the patient as regularly as they may prefer.
When giving consideration to writing a report to prevent future deaths Coroners are
not limited to deaths which are felt to have been contributed to by the issue causing
the Coroner some concern. As stated above the care afforded to Mrs Burns did not in
my view alter the outcome for her but this should not prevent this report being written
if I believe the duty upon me is met.
I received impressive evidence from a Sister whose role was to co-ordinate the
assessment area. She explained that during the entirety of the shift the staff had been
dealing with approximately one third more patients than when they are performing at
what is usually regarded as full capacity. However this was not an isolated incident and
this had been the position throughout December, January, and February and that it has
remained an issue which is persisting and cannot be solely attributed to what is
sometimes described as “winter pressures”.
It may well come as no surprise that the Emergency Department staff is facing these
pressures and it may be that you feel that as a Trust you are doing all that you feel that
you can to minimise the impact caused by the increased workload. Indeed I received
helpful evidence during the inquest from the co-ordinator of the Emergency
Department who explained that efforts have been made to review practices in order to
make the system more efficient and hopefully be able to cope with over-capacity.
Nevertheless, I believe that I have a duty to write this letter because I feel that there is
a risk of future deaths caused or contributed to by staff not having the time to assess
and care for patients due to their workloads meaning any potentially significant
deterioration in a patient’s condition may go unrecognised or is under-appreciated and
with serious consequences.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 24th 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 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 following Interested
Persons:
Burns family
Care Quality Commission
I 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 the release or the publication of your response by the Chief Coroner.
9
A.A.Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 28th April 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.
INHS Blackpool Teaching Hospitals NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool FY3 8NR Telephone: 0125. 14 June 2018 Mr Alan Wilson Senior Coroner for Blackpool & the Fylde Municipal Buildings Corporation Street Blackpool FY1 1GB Dear Mr Wilson Re: Regulation 28 Report to Prevent Future Deaths — Mrs Catherine Burns | write in response to your Regulation 28 report to prevent future deaths dated 28 April 2018 relating to the care of Mrs Catherine Burns. Having reviewed your Regulation 28 | initiated a review of the care which Mrs Burns received whilst an in-patient at the Trust. You raised the following concerns which | shall address in turn. ! am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been. In response to the increase demand on ED, the Emergency Department has undertaken a Capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration. Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely. ! am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a doctor for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer. The Better Care Now programme led by myself as Medical Director is in place to improve patient flow through the whole health system. As this programme begins to deliver, the pressure of overcrowding in the Emergency Department will begin to ease. As part of that programme of the work, the Department is developing an Escalation and Surge Protocol to help coordinate a consistent and effective response to an increase in demand. The criteria for escalation has been agreed and includes an escalation in the wait to be seen. Actions are being assigned to support the nurse and doctor in charge of the Emergency Department to manage the pressure effectively and gain the support required to de-escalate. Escalation is being assessed through two hourly Safety Huddles and six times daily at bed meetings. RESEARCH MATTERS AND SAVES LIVES - TODAY'S RESEARCH IS TOMORROW'S CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence Providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. disability) / g Health & care | Interim Chair: Mark Cullinan information GIES confident} | x youcan trust) Chief Executive: Wendy Swift COMMITTED fais When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if | believe the duty upon me is met. | received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full Capacity. However this was not an isolated incident and this had been the Position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”. Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment as close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department: e Use of the SAFER care bundle to improve patient management on wards and discharge planning. e Introduction of a centralised control room to improve the operational management of patient flow through the health system. e Maximising Ambulatory Emergency Care pathways to ensure that any patients that can be managed outside of the Emergency Department are managed in a different care model. e Mental Health pathways — identifying alternative routes of support for mental health patients in crisis. e Introducing therapies in to the Emergency Department to improve the speed of decision making and so accelerating decision for either admission or discharge and, therefore reducing overcrowding. e Triage nurses on reception — improved streaming to the Urgent Care Centre and fast initial assessment. In your letter you went on to recognise the increased work load that the Trust in general and the Emergency Department in specific is experiencing. You will realise from the national press that these pressures are not peculiar to this health economy but affect major parts of the NHS. None of which is to Say that the Trust is in any way complacent about the matters that you have raised as concerns. | hope that the extensive work described above gives some assurance that measures are being taken to mitigate the ongoing pressures as far as practicable. Yours sincerely PROFESSOR MARK O’DONNELL MEDICAL oo
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