Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0213, written 4 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jul 2018 |
|---|---|
| Reference | 2018-0213 |
| Deceased | Kathleen Allen |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham 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 THIS REPORT IS BEING SENT TO: University Hospitals Birmingham NHS Foundation Trust 1 CORONER I am Miss Emma Brown, Area Coroner for Birmingham and Solihull 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 27 March 2018 I commenced an investigation into the death of Kathleen Margaret Allen. The investigation concluded at the end of an inquest on 27 June 2018. The conclusion of the inquest was Natural causes contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH The Deceased died at the Birmingham Heartlands Hospital on the 20 March 2018 due to the effects of aspiration pneumonia caused by small bowel obstruction. She had been admitted at 15:12 on 18 March 2018 with a history of vomiting and was diagnosed with gastroenteritis. An abdominal x-ray was requested at 20:07 to exclude bowel obstruction but was not carried out until many hours later as the correct procedure was not followed simultaneously the severity of her condition was not identified because she was not reviewed by a Senior Doctor and her observations and modified early warning score were not being monitored frequently enough. The gravity of her condition was identified when her MEWs was taken at 12:40 on the 19 March 2018 prompting senior medical review and x-ray resulting in the diagnosis of small bowel obstruction secondary to a femoral hernia and surgery was undertaken at 06:20 but the Deceased was too poorly to benefit from the surgery. With prompt diagnosis, intervention and treatment Mrs Allen’s death was preventable. Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a) MULTI ORGAN FAILURE 1b) OBSTRUCTED RIGHT FEMORAL HERNIA (OPERATED) 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. The Mews Chart contained within Mrs Allen’s A and E records was the Heart of England NHS Foundation Trust ‘Adult MEWS Observation Chart’. The Escalation Pathway was clearly set out providing that for a MEWs of between 1 and 3 there should be consideration of increasing frequency of observations and “Inform Nurse in Charge”. 2. The evidence of the staff nurse caring for Mrs Allen during the evening of the 18 March was that he did not alert the Nurse in Charge when Mrs Allen’s MEWS went up to three (having gradually risen from 0 at the time of arrival) because A and E nurses had been told that this part of the escalation pathway did not apply in A and E. He did not consider increasing the frequency of her observations at the time but on reflections said they should have been hourly, he could not explain why he hadn’t done this. He went on to explain that since Mrs Allen’s death he has been told that he should escalate to the Nurse in Charge a patient with a MEWS between 1 and 3. 3. Evidence was provided from an ED Senior Sister that there is a Trust Standard Operating Procedure (SOP) for MEWS Triggers in the Emergency Department which is different to the Trust wide SOP. The rationale behind having a different Procedure in ED was said to be because Doctors are more widely available in ED than on the wards. Within this SOP a MEWS of between 1 and 3 is not escalated to the Nurse in Charge. It was accepted by the witness that the rationale for a different procedure based on Doctor availability does not explain why the Nurse in Charge is not informed for a patient with a MEWs of 1 to 3. It was suggested that the explanation for this may in fact be because so many ED patients have a MEWS of between 1 and 3 the Trust wide MEWS SOP would be unworkable. A copy of this Procedure was not put before the inquest but was said to still be in operation at Birmingham Heartlands Hospital. It therefore appears that there is not a consistent approach to MEWS SOP in Birmingham Heartlands ED: members of staff are being told different things and there appears to be a different procedure in operation to that set out in documents within patient records. There is a risk that staff within ED will not be taking a consistent, evidence based approach to MEWS and also that non ED based clinicians, reviewing patients in ED will not be aware of the difference in MEWS procedure operating in ED and therefore will expect a different escalation pathway. This could put lives at risk. 4. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 28 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the next of kin of Mrs Kathleen Allen. I have also sent it to NHS England who may find it useful or of interest. 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 04/07/2018 Signature Miss Emma Brown Area Coroner Birmingham and Solihull
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.
University Hospitals Birmingham INHS NHS Foundation Trust Trust Headquart Executive Office of the Chairman & Chief Executive meee Sei Chairman ; Queen Elizabeth Hospital Birmingham Chief Executive : Mindelsohn Way Executive Manager: Edgbaston Fax 2 Birmingham B15 2GW Your Ref: | 124069- KATHLEEN MARGARET ALLEN (LH/RP) Tel: 0121 627 2000 Our Ref: DRLTR/HUNT 2808 2018 28 August 2018 Mrs Louise Hunt HM Senior Coroner Birmingham and Solihull Areas 50 Newton Street Birmingham B4 6E Dear Mrs Hunt INQUEST INTO THE DEATH OF MRS KATHLEEN MARGARET ALLEN - REPORT TO PREVENT FUTURE DEATHS | write in response to your letter dated 4 July 2018, regarding the Regulation 28 Report made by Miss Emma Brown, Area Coroner, following her investigation and inquest into the death of Mrs Kathleen Margaret Allen on 27 June 2018. University Hospitals Birmingham NHS Foundation Trust (the “Trust”) has carefully considered the important matters of concern raised within the Prevention to Prevent Future Deaths Report and the Trust's response is as follows: The Trust recognises the concerns with regards to the apparent inconsistent approach to the MEWS Standard Operating Procedure (SOP) in BHH ED and the lack of consideration given to increasing the frequency of patient observations and the lack of escalation to the Nurse in Charge as the clinical condition of the patient deteriorated. The MEWS escalation pathway in ED does differ from that which applies to the wards. As the Area Coroner identified, the escalation pathway documented on the back of Mrs Allen's MEWS Observation Chart required, for a MEWS score of between 1 and 3, consideration of increasing the frequency of observations and escalation to the Nurse in Charge. In ED, however, for a MEWS score between 1 and 3, there is an expectation that patient's observations are completed hourly, but escalation to the Nurse in Charge is not routinely required unless there is an overriding clinical concern or deterioration in the patient's condition (that is to say, the MEWS is a safeguard, but clinical staff should not allow it to override their clinical judgement). Chair: Rt Hon Jacqui Smith Chief Executive: Dame Julie Moore The rationale behind the differing escalation pathways is that, on initial presentation, ED patients often have a MEWS score that, on a ward, would trigger escalation. However, for many such patients, the ED rapid assessment, intervention and treatment quickly reduces the MEWS score significantly. If the Trust ward MEWS escalation pathway was applied to ED there would be an unnecessary level of escalation for a cohort of patients with a MEWS between 1-3 who are stable and have a management plan that is being followed to allow a period of time for the prescribed treatment to take effect. Whilst a different MEWS Observation Chart showing the ED specific escalation pathway has not, historically, been used in ED, as part of their local departmental induction, all ED staff are made aware of the ED specific MEWS escalation pathway and are required to complete MEWS competencies and assessed using clinical scenarios to ensure theory and practice is embedded. Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED- specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use. Finally, in relation to Mrs Allen, the named Nurse who was caring for her had completed all his local departmental competencies. However, irrespective of any confusion regarding the escalation pathway, Mrs Allen should have been escalated to the Nurse in Charge notwithstanding her MEWS being between 1 and 3, because of her deterioration. Unfortunately, the Nurse failed to recognise the gradual and subtle changes in Mrs Allen's condition whilst in the Emergency Department. The named Nurse responsible for the care of Mrs Allen has received a period of supervised practice whilst working in a supernumerary capacity and has completed targeted objectives relating to recognising and care of the deteriorating patient. This has been managed using the Trust's Performance and Capability Policy. | trust that the above addresses the concerns sufficiently. If you require any further information, please do not hesitate to contact me. Yours sincerely 7 Dr Dave Rosser Deputy Chief Executive cc Emma Brown, Area Coroner pe Director of Corporate Affairs.
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