Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0190, written 14 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jun 2018 |
|---|---|
| Reference | 2018-0190 |
| Deceased | Alfred Meek |
| Coroner | Sarah Slater |
| Coroner area | South Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Mrs Sarah Louise Slater Assistant Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster Royal Infirmary, Armthorpe Road, Doncaster DN2 5LT CORONER | am Mrs Sarah Louise Slater, Assistant Coroner for South Yorkshire (East District) 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 27" September 2017 | commenced an investigation into the death of Alfred William Meek. The investigation concluded at the end of the inquest on 14th June 2018. The conclusion of the inquest was that Mr Meek died from: 1(a) Pneumonia 1(b) Subdural Haemorrhage A short form conclusion of Accidental Death was recorded in Box Four and Box three completed in the following term: Mr Meek had an unwitnessed fall on or around the 30" August 2017 but he did not receive any medical attention following this. However, Mr Meek was admitted to Doncaster Royal Infirmary on the 2" September 2017 after sustaining head and facial injuries in a fall at his home. On the 12'" September 2017, whilst in the hospital, Mr Meek suffered a further fall on Ward S12. Mr Meek died on the 13"° September 2017 as a consequence of traumatic head injury. However, it is not possible to attribute this injury to a specific fall. CIRCUMSTANCES OF THE DEATH Mr Meek was an 87 year old gentleman who suffered with some cognitive impairment due to dementia. He lived independently but his family had increasing concerns because he had on occasions let himself out of the house and been found wandering at inappropriate times. Mr Meek suffered an unwitnessed fall by a lake on or around the 30" August 2017. An ambulance was called by a member of the public and Mr Meek was taken to the Emergency Department of Doncaster Royal Infirmary. He was later joined by his son who described his father as wanting to go home and was becoming increasing frustrated at the long wait. There were no visible injuries and therefore Mr Meek took his father home. On the 2" September 2017, Mr Meek was admitted to Doncaster Royal Infirmary having fallen at home and suffered obvious head and facial injuries. Mr Meek was underwent an Enhanced Care Supervision assessment and was initially assessed at Amber which requires intermittent observations and to be nursed near the Nurses Station. The Policy States that the assessment should be reviewed daily. However, four days lapsed before a further review took place. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 A review of the Enhanced Care Supervision on the 8" September 2017 assessed Mr Meek as Red requiring continual cohort supervision because he was not compliant with the use of his call bell due to his dementia and his risk of falls was high. On the 9" September 2017, the nurse in charge of Ward S12 determined that there was insufficient resources available to provide this level of supervision to Mr Meek and escalated this to the site manager accordingly. There was no evidence before the Court that this escalation of concern from the nurse lead to any further action by the Trust. On the 10" September 2017, Mr Meek was still considered a Red risk, but the Trust is unable to identify what level of supervision Mr Meek received. On the 11" September 2017 no review of the Enhanced Care Supervision Plan occurred and the Trust is unable to identify what level of supervision was in place. However, it was evident that when Mr Meek suffered a fall during the early hours of the 12'" September 2017, the required cohort nursing was not being provided. Mr Meek’s Enhanced Care Supervision plan was updated following his fall to Purple which requires one to one supervision. Mr Meek died on the 13" September 2017 as a consequence of Pneumonia secondary to Subdural Haemorrhage. 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) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments. There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient's vulnerable to falls. 2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified. The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced care Supervision and its implications, — concerned that this situation could occur again. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have 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 Thursday 9th August 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: land The Rt Hon Jeremy Hunt, The Secretary of State for Health and Social Care, Department of Health. | 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. Dated 14 June 2018 ) Signature. CL a Assistant Coroner for South Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
Assistant Coroner for South Yorkshire (East District) 9 August 2018 Ref: Regulation 28 Letter relating to the Inquest of Mr Alfred William Meek Further to your Regulation 28 letter sent to the Chief Executive of Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest of Mr Alfred William Meek, I have been asked to provide the Trust response to your concerns. The first concern in your letter was regarding gaps in the reliability of daily reassessment and appropriate intervention. In response to this concern, I can confirm that our policies and documentation are designed to achieve an appropriate frequency of reassessment and appropriate interventions. The reliability of daily assessment and appropriate intervention can be seen through monitoring with regular audits. The total results for ward S12 are: 25/6/18 9/7/18 16/7/18 23/7/18 Patient records audited Overall compliance 14 13 15 10 97.1% 95.7% 96.5% 96.1% The Trust Falls Specialist Practitioner has also undertaken audits across the Trust and these can be found appended to this letter. This shows a broadly high level of compliance in respect of assessments being undertaken at the appropriate frequency and action for supervision being taken. There are some areas for improvement on the implementation of the relevant actions to address a patients specific falls risk factor/s and de-escalation interventions, which is supported through the training provided, subsequently described in this letter. The second concern described in the letter was about the action taken following escalation. The investigation report found that the staff did not escalate any staffing needs, as they had not recognised the need for Mr Meek. This aspect relates to the reliability point above and there are systems in place through the Enhanced Supervision & Engagement Policy. The following steps set out the systematic approach that is in place to manage staffing resources optimisation: 1 Initial management to provide appropriate supervision When a need for supervision is indicated then the nurse in charge of the ward would allocate resources to achieve this from the existing staff on the ward in the first instance. This may create a need for redistribution of work for the rest of the team, or if there is insufficient staffing to achieve this then the matron or a senior member of nursing staff should complete the enhanced care prescription assessment (Enclosure 1). Enhanced Care Prescription This tool verifies the assessments undertaken and validates that all of the appropriate interventions have been taken to reduce the risk for an individual patient. This would include a range of potential supporting interventions to help the patient be oriented and supported. The assessment tool also makes a recommendation for cohorted or 1:1 supervision above the planned staffing level. Staffing levels are planned according to the acuity of patients using the Safer Nursing Care Tool, which takes into account the need for supervision. The need may be within the expected staffing level, but where it is above normal staffing level then the Enhanced Care Prescription provides authorisation to permit additional staff. Access to additional temporary staff The Trust is resourced with finite financial support, but when there is a clinical need for additional resources, additional resources will be requested from the nursing bank, provided by NHS Professionals. The fill rate for NHS Professionals is at about 80% of the demand for Heath Care Assistants, who are the staff group booked for supervision needs. Staff who already work for the Trust are asked to undertake additional duties, prioritised on part time staff, but would include overtime when other options have not been successful. If there is no-one available despite these attempts, then staff may be redeployed to spread the risk and optimise patient safety and safe staffing levels across the hospital. A limitation remains in achieving short notice responses, exacerbated when there is sickness and absence that creates additional demands for temporary staffing. A report on the overall and ward level position for our actual staffing against the planned level is reported to a national staffing return and also reported through the Trust governance arrangements, including a report to the Board of Directors as part of the performance report each month. The Trust has a strategic approach and focus on preventing falls, with the development of policies, assessment tools and compliance to NICE guidance in respect of falls prevention. As a Trust we are committed to reducing inpatient falls and improving our learning from falls. To facilitate this we have developed a standard Trust action plan which meets the minimum standards we would expect to see after a fall resulting in moderate harm, severe harm or death. Tier 2 falls prevention and management education including falls documentation is provided to all frontline Trust staff within the Person Centred Care study day. To date 1029 Trust staff have received this training over 2 years, this is ongoing, bi-monthly training enabling up to 100 staff to attend at each session. The Trust action plan for Falls & Bone Health Management supports the falls ward accreditation to be implemented this year. This is similar to other accreditation initiatives already in place such as nutrition and infection control. The falls accreditation will provide proactive assurance of the work 2 the wards are doing to improve quality proactively, rather than responding after an event has occurred. The accreditation will be monitored by the falls prevention practitioner to identify areas requiring additional support and training to ensure quality improvements are being made in all areas within the Trust and to further embed the education and documentation. To achieve accreditation: 75% of falls champions (one on each ward) to attend the quarterly training event. Records to be kept by the falls prevention practitioner. 50% of all ward staff to have attended the Person Centred Care study day. Records kept my training and development department. 90% of staff trained on the daily supervision and engagement assessment, enhanced care plan and safety side assessment. Ward Manager to keep register of staff signed off. 95% compliance with a monthly audit on 5 sets of notes each month, looking at compliance against the daily supervision and engagement assessment, enhanced care plan and safety side assessment The accreditation process feeds in to the Quality Assurance Tool, so all areas have a series of quality and performance processes, designed to improve the quality of care provided. I trust that this provides an assurance that there are systems in place to manage staffing to supervise patients and monitoring of the reliability of staff undertaking assessments. The Trust prioritises patient safety and provision of high quality care. The lapses in care in this case are accepted and action is being taken to improve. I would also like to offer my condolences to Mr Meek’s family following his death. Kind regards Deputy Director of Nursing, Midwifery and Allied Health Professionals 3
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