Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0139, written 9 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2018 |
|---|---|
| Reference | 2018-0139 |
| Deceased | Kirsty Tolley |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CHIEF EXECUTIVE QUEEN ELIZABETH HOSPITAL KING’S LYNN NHS FOUNDATION TRUST GAYTON ROAD KING’S LYNN NORFOLK PE30 4ET 1 | CORONER | am JACQUELINE LAKE, Senior Coroner, for the Coroner area of NORFOLK 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 21 February 2017 | commenced an investigation into the death of KIRSTY ELIZABETH TOLLEY, AGED 28 YEARS. The investigation concluded at the end of the inquest on 8 MAY 2018. The conclusion of the inquest was Medical Cause of Death: Unascertained. Conclusion: Open. 4 | CIRCUMSTANCES OF THE DEATH Miss Tolley had a number of issues of ill-health. On 10 February 2017 she was admitted to Queen Elizabeth Hospital with leg pain and high temperature. Her haemoglobin level on entry was 77 g/l which dropped to 61 g/l by 16 February 2017. Ferinject treatment was started. Miss Tolley was reviewed by a number of specialities. She was being considered for discharge home. On 19 November 2017 Miss Tolley was found unresponsive in her bed. Despite resuscitation she was declared dead. 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) Miss Tolley had a history of anaemia and had received a blood transfusion in 2016. On admission the Care Plan required blood tests to be taken daily to check haemoglobin levels. These were carried out on 10", 13", 14" and 16" (not daily) and showed decreasing levels. Ferinject was administered on 16" February. No blood tests to check haemoglobin levels were carried out after that date (except whilst in cardiac arrest). Blood tests were not carried out daily as required in the Care Plan, despite the requirement for monitoring, her history, the decreasing level of haemoglobin, and Ferinject being administered. There is no reason given in the Care Plan. Evidence was heard with regard to a Regulation 28 Report, that haemoglobin levels are not checked in the few days after Ferinject is administered as its effect is not seen straight away. This was not raised as a reason for not carrying out blood tests in evidence at the inquest. This was not recorded as a reason in the medical records. Sadly, not only did this not give treating Doctors a picture of Miss Tolley's anaemia during her lifetime but has also meant there is a vaccum of evidence with tegard to the medical cause of death. (2) Early Warning Scores (EWS) are required to be assessed and recorded 3 times per day. This was not done at lunchtime on 11 February nor evening time on 17 February 2017. No reason has been given for this. (3) Evidence was heard that if EWS reaches 3, then this should be escalated to a doctor who should review the patient and set a plan. Observations should be increased to 4 times per hour with further review. The EWS reached 3 on 4 occasions (including the occasion when the EWS was not completed in the records — 17 February) and there is no evidence that any additional action was taken. In particular on the 17 February no observations/EWS for over 17 hours. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4 July 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- :....: | have also sent it to the Department of Health, HSIB and Healthwatch, Norfolk who may find it useful or of interest. lam 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 May 2018 ‘ late : isis teeny si COOKER ve Norfolk Coroner Service Carrow House, King Street Norwich NR12TN
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.
~ 7 SUL 2018 INHS| The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Gayton Road King’s Lynn Norfolk PE30 4ET 26 June 2018 www.qehkl.nhs.uk Mrs J Lake HM Coroner for Norfolk Tel: 01553 613613 301 King Street NORWICH NR1 2TN Dear Mrs Lake Response to Regulation 28 report Further to the Regulation 28 Report dated 9" May 2018 | am pleased to respond as follows to the matters of concern you raised in your letter. (1) Upon the patient's admission the admitting consultant, EE wrote in his management plan that Kirsty was to have daily bloods. That plan clearly varied subsequently but his initial plan was based upon his clinical assessment at the time. | think it is important to note that our admission document (Clerking Proforma) is not regarded as a rigid tool, perhaps as is seen with documentation like the Waterlow assessment or falls risk tools, for example. From the medical point of view the plan may, and should, change as different doctors subsequently review the patient and or the condition or working diagnoses change. In fact | would expect subsequent doctors visiting a patient always to have in mind an inquisitive and challenging approach to initial working diagnoses and management plans, and be prepared to alter them. There are times when the patient condition, working diagnosis or even opinions of the attending physician may be at variance with views expressed in an earlier consultation during an admission. However, it is not standard practice to formally deal with each of the previous medical entries; unless perhaps there was a serious reason to question the validity of the initial opinion, which there wasn't in this case. | have taken counsel from a number of physicians on the facts of this case, each of whom would have managed the case slightly differently as it unfolded. | wonder if this contributed to the sense there was an evidential vacuum. For example, if other doctors had been called, they may well have given other different views on the same facts. With the benefit of hindsight | suspect this is also the reason why it was difficult for us to anticipate how to provide the best information for you beforehand. Please be reassured that this organisation will continue to strive to provide all necessary information to the Coroner in her investigations and deliver the best possible assistance on the day in court. (2) and (3) The Trust currently uses the Early Warning Score (EWS) system to detect early signs of a patient's deterioration. On this occasion the readings were not adequately recorded and the appropriate escalation did not occur in a timely fashion. 27 June 2018 The Queen Elizabeth Hospital King’s Lynn NHS Trust The staff, both nursing and medical, working in that clinical area have received support to ensure that they understand and are able to use the current escalation system. The Trust recognises however that a wider and more comprehensive review is needed to ensure that early warning systems are consistently in place across the whole Trust. The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018. This will necessitate new documentation, training and escalation procedures and, in order to avoid confusion, the Trust has decided not to undertake widespread retraining on the older escalation procedures between June and November 2018. Our timetable is set out below: May 14 Agreement to adopt NEWS2 on 1 November 2018 May 16 Appointment of NEWS2 Champion June 11 NEWS2 Implementation Group formed with reporting to Trust Clinical Governance Committee September 1 Countdown to NEWS2 (communication and training) November 1 NEWS2 go live This will be followed by an ongoing audit to ensure appropriate documentation and audit of escalation. Please let me know if you require any further assistance. on behalf of Jon Green, Chief Executive Officer Page 2 of 2
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