Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0342, written 6 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2018 |
|---|---|
| Reference | 2018-0342 |
| Deceased | Gerwyn Thomas |
| Coroner | Jonathan Layton |
| Coroner area | Camarthenshire and Pembrokeshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of West Wales General Hospital Glangwili Carmarthen 1 CORONER I am Jonathan Mark Layton, senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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 2nd July 2018 commenced an investigation into the death of Gerwyn James Thomas. The investigation concluded at the end of the inquest on 6th November 2018. The conclusion of the inquest was a narrative conclusion as follows: Following a domestic fall Gerwyn James Thomas was admitted to Glangwili General Hospital on 21 March 2017 with a fractured femur. He underwent surgery but developed an infection, the origin of which is unknown, which caused his death. A referral made to the acute diatetic service was not responded to in a timely manner. Gerwyn James Thomas’ compromised nutritional status may have impaired his ability to resist this infection. The medical cause of death was: 1(a) sepsis, multi-organ failure 1(b) infected hip surgery 4 CIRCUMSTANCES OF THE DEATH (1) Mr Thomas was admitted to Glangwili Hospital on 21st March 2017 following a domestic fall where he fractured his femur. This required surgery. (2) Mr Thomas was discharged. Subsequently he was readmitted to hospital three times after he developed an infection which was treated but which subsequently resulted in his death. (3) A referral was made to the acute diatetic service which was not acted upon promptly. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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 acute diatetic service lacks sufficient staff to respond to referrals in a timely 1 way. 2. The use of the diagnostic tool to assess a patient’s nutritional need, which nursing staff apply when a patient is admitted, requires training. When wrongly applied, this diagnostic tool will give an unreliable assessment. Training in the use of this diagnostic tool should be made mandatory for all nursing staff. 3. When a treating doctor identifies a need for a patient to be referred to the acute diatetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. 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 the 1st January 2019. 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 Person: 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 6 November 2018 Signed: 2
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.
| Swredd lechyd Prifysgol Hywel Dda University Health Board Springfield . Ysbyty Cyffredinol Liwynhelyg Ein cyf/Our ref: HDA/886 Heol Abergwaun, Hwiffordd, Gofynnwch am/Please ask for: Claire Pickett Sir Benfro, SA61 2PZ Rhif Ffén /Telephone: 01437 834417 E-bost/E-mail: Claire. Pickett@wales.nhs,uk Springfield . t Withybush General Hospital Date: 21* December 2018 Fishguard Road, Haverfordwest Pembrokeshire, SA61 2PZ Mr M Layton H M Senior Coroner for the areas of Carmarthenshire and Pembrokeshire Coroner’s Office Town Hall Hamilton Terrace Milford Haven Pembrokeshire SA73 3JW Dear Mr Layton Inquest touching upon the death of Mr Gerwyn Thomas Further to the issue of a Regulation 28 report in respect of the above inquest, which was received by the Health Board on 6" November 2018 please see below the Health Board’s response to each of your recommendations. May | take this opportunity to express my sincere condolences to Mrs Thomas on the loss of her husband. The matters of concern that you raised are as follows, with the Health Board’s responses underneath: 1. The acute dietetic service lacks sufficient staff to respond to referrals in a timely way. The dietetic service is actively working to address the staffing deficit in acute services via the following actions: Cadeirydd / Chair Swyddfeydd Corfforaethol, Adeilad Ystwyth, Corporate Offices, Ystwyth Building, ‘ Hafan Derwen, Parc Dewi Sant, Heol Ffynnon Job, Hafan Derwen, St Davids Park, Job’s Well Road, Mrs Bernardine Rees OBE Caerfyrddin, Sir Gaerfyrddin, SA31 3BB Carmarthen, Carmarthenshire, SA31 3BB Prif Weithredwr / Chief Executive Mr Steve Moore Bwrdd lechyd Prifysgol Hywel Dda yw enw qweitiredol Bwrdd lechyd Lleo! Prifysgol Hywel Dda Hywel Dda University Health Board is the operational name of Hywel Dda University Local Health Board Mae Bwrdd lechyd Prifysgol Hywel Dda yn amgyichedd di-fwg Hywel Dde University Health Board operates a smoke free environment Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue. During November and December it has not been possible to secure adequate locum support to cover existing acute service vacancies; this has necessitated contingency arrangements to ensure patients at the greatest risk are rapidly flagged to dietetics for prioritisation and an enhanced ward based nutritional care pathway has been initiated to reduce the risk of not having timely dietetic access. Recognising the lack of acute dietetic staffing, and with Executive approval, the service has attempted to ‘over recruit’ to increase acute dietetic staffing above establishment; unfortunately to date this has not led to an increase in staffing because of the low number of applicants as indicated above. Recruitment of dieticians is a recognised current challenge for Health Boards across Wales and services have recommended an increase in the number of commissioned training places. To address the staffing shortfall sustainably, dietetics have proposed an increase in acute dietetic staffing in the service submission to the Health Board intermediate plan, with an incremental increase in registered dieticians and unregistered dietetic support workers. . The use of the diagnostic tool to assess a patient's nutritional need, which nursing staff apply when a patient is admitted, requires training. When wrongly applied, this diagnostic tool will give an unreliable assessment. Training in the use of this diagnostic tool should be made mandatory for all nursing staff. In October 2018 the dietetic team initiated a programme of refresher training for Registered Nursing staff in Adult In-Patient locations regarding the current Nutrition Screening Tool which is used to screen a patient’s risk of malnutrition. Additional training sessions have also been provided by the Dietetic team for ward nursing teams when requested. The NHS Wales Food Record Chart: All Wales E Learning programme is a mandated E-learning module. This was established to support the introduction of the All Wales Hospital Nutrition Care Pathway (of which nutrition risk screening is the first step) and the All Wales Food Chart. The Health Board will be asked to approve the adoption of a different Nutrition Screening Tool for Adult In-Patient services as part of the All Wales project to digitise nursing documentation in secondary care. The proposed tool has been submitted via the National Dietetic and Page 2 of 3 Nutritional Group as the recommended evidenced based tool. The new screening tool as a component of the wider documentation project aims to be ready for full implementation by November 2019. e The preparation phase for implementing the new screening tool in Hywel Dda University Health Board will provide the opportunity to undertake a wide scale nutrition screening training for nurses within adult In-Patient areas. The proposed nutrition screening tool, as with the current tool, identifies a patient’s malnutrition risk, patients screened at high risk require dietetic referral to enable a full nutritional assessment to be undertaken 3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi- disciplinary team meeting. The Head of Nursing at Glangwili General Hospital has sent a memo to all ward staff detailing the action required by the Coroner and how they are to achieve this. She will be asking for every nurse to read the memo and sign to say they have done so and understand their responsibilities. This will then be shared with the wider nursing teams through the Heads of Nursing at the other sites across the Health Board. | hope the actions outlined above will satisfy you that appropriate steps have been and are being taken to create a robust dietetic service within the Health Board and that patient safety remains an upmost priority for all staff within the Health Board. Yours sincerely Steve Moore Chief Executive Page 3 of 3
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