Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0192, written 22 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 | 22 Jun 2018 |
|---|---|
| Reference | 2018-0192 |
| Deceased | Graham Fox |
| Coroner | Robert Sowersby |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Bristol NHS Trust |
| 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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 8th June 2018 REF: 7089 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Robert Woolley - Chief Executive University Hospitals Bristol NHS Trust Trust Headquarters Marlborough Street Bristol BS1 3NU CORONER | am Robert Sowersby Assistant Coroner for Area of Avon 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 12" July 2017 an investigation commenced into the death of Graham William FOX. The investigation concluded at the end of the inquest on 8 June 2018. The conclusion of the inquest was that he died of (la) chronic obstructive pulmonary disease and pneumonia, and (II) left hip fracture (operated) and ankle fractures. My narrative conclusion included the following: His condition deteriorated, and overnight from 25 June hospital staff did not correctly implement the standardised method of assessment and referral [‘NEWS’] that was in use at the time, which meant that he was not seen by a doctor as he should have been, and the seriousness of his condition was not recognised until 26 June, when he was admitted to the Critical Care Unit in which he subsequently died. CIRCUMSTANCES OF THE DEATH Mr Fox had a history of alcohol misuse and had had a fall in the community in which he broke both ankles. He was admitted to hospital and was being monitored using the NEWS system. He had been “re- triggered” by the hospital’s doctors, so that although normally an oxygen saturation, or a blood pressure reading, below a certain level would add points to the NEWS total, in Mr Fox’s case points would not be added unless his score dipped below the new revised (“re-triggered”) level. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL Mr Fox’s ‘normal’ NEWS was 5, after which he was reviewed, “re-triggered”, and when later assessed his score was 5 again (using the new re-triggered means of NEWS assessment). That represented a real- world deterioration in his condition, but because the number itself did not go up, the nursing staff were relatively unconcerned. The NEWS of 5 was in due course relayed to the on-call doctor, but the doctor did not attend, even though she was on the same ward seeing another patient that evening. Mr Fox then had a series of inadequate observations taken overnight (which were not sufficient to enable any calculation of his NEWS total). By the time his NEWS total was properly calculated in the morning it was 9: he was then admitted to the Critical Care Unit, where his condition deteriorated and he sadly died. 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) The standard NEWS documentation contains a list of scores on the left, and corresponding clinical responses in a column on the right. My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory. The impression | gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were ‘required’ when the relevant score was reached were actually necessary. The more senior nursing staff were clear that the relevant responses were mandatory, but that was not the impression given by the more junior staff. This evidence (which gave the impression that staff discretion could be applied to the clinical responses) was given after the staff had, apparently, been given additional NEWS training following Mr Fox’s death. (2) 1 did not have the benefit of any expert evidence about the process of “re-triggering” patients under NEWS, and | am therefore unable to comment on whether it is clinically appropriate. | did hear evidence that the practice was commonplace within the hospital. Telephone 01275 461920 Email AvonCoronersTeam @bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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 17" August 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 — the family of Mr. Fox. | 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. 22/06/2018 Signature a P Robert Sowersby Assistant Corgner Area of Avon Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
ps BSS FRO University Hospitals Bristol NHS Foundation Trust Trust Headquarters Marlborough Street Bristol, BS1 3NU nt i eb-sife: www.unbristol nns.u RW/CM/yq 6 August 2018 Private & Confidential Mr Robert Sowersby Assistant Coroner The Coroners Court Old Weston Road : Flax Bourton BS48 1UL Dear Mr Sowersby RE: Inquest 8" June 2018 — Mr G, Fox — Regulation 28 Report. Ref:7089 Recognition and response to deterioration in patients, escalation process for patients triggering National Early Warning Score (NEWS) Further to your concerns raised to University Hospitals Bristol NHS Foundation Trust in the format of a Regulation 28 Report, | am writing to confirm the Trust’s response and actions. At the inquest, | understand that you raised concerns around there being an element of discretion /clinical judgement applied in determining whether the clinical responses that were required where the relevant EWS was reached were actually necessary and the practice of re-triggering a patient. Since this incident the Trust has implemented an e-observations system in our adult in-patient wards whereby the patient’s physiological measurements are entered electronically into a hand held device, which automatically calculates the national early warning score (NEWS) and prompts the staff member to repeat the observations in the required timeframe and to escalate to the relevant clinician in accordance with the Trust’s escalation protocol. This system allows for the nurse in charge of the ward to have oversight of all patients showing signs of deterioration in the ward, and also allows oversight out of hours of deteriorating patients in our hospitals, by the Clinical Site Team, who are highly skilled and experienced nurses who can | support ward staff in the management of deteriorating patients. The system also allows doctors | and senior nurses to review an individual patient’s physiological parameters remotely. The analytics in this system also provide visibility of any instances when observations have not been i repeated as per the escalation protocol to enable targeted training and support to clinical teams if required. Moy, Mp bey, i BLS University Hospitals Bristol NHS Foundation Trust f lee hed oR A 0117 923 0000 Minicom 0117 934 9869 www.uhbristol.nhs.uk | Our hospitals. 15a At present, such escalation is completed by telephone or in person, but we will shortly be implementing a further clinical communications system (‘CareFlow’) whereby the escalation will be automated to the relevant doctor or senior nurse in accordance with the escalation protocol. The CareFlow system is currently being used in a few areas for some elements of clinical communication. With regards to the practice of “re-triggering”, this perhaps should be more accurately referred to as “revised escalation” and we have been promoting this terminology within the Trust since we commenced implementing the e-observations system towards the end of 2017. Some patients do have elevated early warning scores due to a long term condition which is “normal for them”; in these situations it can be appropriate for a doctor to document a clear revised escalation plan setting out the circumstances when an escalation should be enacted. In situations where a previously stable patient's physiological parameters have prompted the need for a clinical response, and the patient has been reviewed by the appropriate clinician, and the patient has been assessed as being cared for in the correct location within the hospital and there is a clinical management plan with a time for review of its effectiveness, it is appropriate that a revised escalation timeframe can be documented by a doctor. In all cases, a revised escalation plan states that an escalation should be enacted if a nurse is concerned about the patient's condition. We have been supporting the implementation of the e-observations with a further programme of training and education on revised escalation and will continue do so as we switch to the new national early warning score (NEWS2) planned for October 2018. | hope that the information above has answered your concerns and reassures you of the continued focus within University Hospitals Bristol NHS Foundation Trust in improving the recognition and response to deterioration in patients. Yours sincerely, — VET O50 Ky Robert Woolley Chief Executive i AEG, Se es University Hospitals Bristol NHS Foundation Trust * * 0117 923 0000 Minicom 0117 934 9869 www.uhbristol.nhs.uk ie “9; ie Our haspitals. ISAS
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