Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0378, written 6 Dec 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 Dec 2018 |
|---|---|
| Reference | 2018-0378 |
| Deceased | Simon Healey |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| 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.
Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr Andrew Jones – CEO, Ramsay Healthcare UK, Level 18 Tower 42, 25 Old Broad Street, London EC2N 1HQ. 2. Mr David Hare - CEO, Independent Healthcare Providers Network, Floor 15, Portland House, Bressenden Place, London SW1E 5BH. 1. CORONER I am Mrs Heidi J Connor, Senior Coroner for the coroner area of Berkshire. 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 I conducted an Inquest into the death of Simon Healey that was heard at Reading Town Hall between 3rd and 5th December 2018. I recorded a narrative conclusion as follows: Simon Healey suffered a recognised complication of bowel surgery performed on the 1st August 2017. Opportunities for earlier detection of an anastomotic leak and subsequent sepsis were missed. If this had been detected at any point up to the 6th August 2017, it is likely that he would have survived. He died on the 10th August 2017. 4. CIRCUMSTANCES OF THE DEATH The family asked us to refer to the deceased as Simon at the inquest. I have reflected that request in this report. Classification: OFFICIAL-SENSITIVE -1- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Simon Healey was born on the 29th January 1957. He underwent a right hemi- colectomy at Berkshire Independent Hospital on the 1st August 2017. The operation was performed by , consultant colorectal surgeon, who had performed numerous operations like this before, the vast majority of these in an NHS setting. The immediate post-operative period was uneventful. By the night of 4th August 2017 however, Simon’s NEWS score was 6 (at 10.30 hrs), and 7 (at 22.00 hrs). His CRP was 607. He had not passed urine. He was tachycardic with a raised respiration rate. prescribed He was started on the sepsis pathway by nursing staff and antibiotics. NEWS protocols were not followed in terms of frequency of reviews or considering escalation of care. Simon’s NEWS scores initially came down to 4 in the early hours of the 5th August but he was again scoring 7 at 04.50, 05.50 and 06.50 on that day. I heard no evidence of consideration of Simon’s care being escalated at any point during his stay at the Berkshire Independent Hospital. The junior doctor (RMO) looking after Simon became concerned about his condition on the night of the 6th August. Nursing staff also considered that Simon was not making the progress that they expected after this operation. A decision was taken to carry out an x-ray on the morning of the 7th August 2017. This x-ray revealed free gas and fluid in the abdomen. was called, and attended to review the patient at 16.50 hrs. Simon was transferred to the Royal Berkshire Hospital, arriving there at 19.45 hrs. A CT scan revealed the presence of air and free fluid and Simon’s clinical condition continued to deteriorate. He was taken back to theatre by and a surgical registrar. A defect in the anastomosis was seen and a litre of fluid (including pus) was removed. The defect was sewn over with an omentum patch, the abdomen was washed out and an ileostomy was made. Simon’s condition on the ICU continued to deteriorate, with clear signs of organ failure. He suffered a myocardial infarction on the 9th August 2017. Simon was taken to theatre for a final time on 10th August 2017, when the anastomosis was taken down. There was by then a more obvious defect in the anastomosis with faecal contamination. His bowel was noted to be dusky, because of the ongoing sepsis process and the Noradrenaline he had required because of his low blood pressure. The septic process continued after this third operation, and Simon died in the afternoon of 10th August 2017. A post mortem has revealed the cause of death to be: 1a 1b 1c E.coli Septicaemia Faecal Peritonitis Anastomotic Leak Classification: OFFICIAL-SENSITIVE -2- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1d 2 Elective right hemi-colectomy for the management of colonic carcinoma Hypertension. I had the benefit of independent expert advice, from a consultant colorectal surgeon, Professor Scholefield. The key points arising out of his opinion were: 1. He considered that anastomotic leak should have been suspected and detected by the 5th August 2017. He did not believe that it was reasonable to continue to treat the most likely cause of Simon’s symptoms as ileus by the 5th August. It would have been preferable to investigate the possibility of the more serious complication of leak, particularly in view of Simon’s observations, blood test results and the period of time that had by then elapsed since the original operation. 2. If an anastomotic leak had been detected at any point up to 6th August 2017, then on balance, Simon would have survived. 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 could occur unless this action is taken. In the circumstances it is my statutory duty to report to you. I have included the Independent Healthcare Providers Network in this report because it is likely that some of the issues raised in this case would be relevant to a number of private healthcare providers. As set out in the case of R (Dr Siddiqi and Dr Paeprer-Rohricht) v Assistant Coroner for East London, the issuing of a Regulation 28 Report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature. For the avoidance of doubt, a response is required from Ramsay Healthcare for each of the issues referred to below. The IHP Network need only respond to issues 1 and 2. The MATTERS OF CONCERN are as follows: (1) I believe that the NEWS policies in place at private hospitals should be reviewed. This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell. Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant’s availability to attend and review the position. The Royal College of Physicians NEWS trigger thresholds Classification: OFFICIAL-SENSITIVE -3- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS have been adopted almost verbatim by this hospital, save for the category relating to the sickest patients. Whilst the trigger thresholds in the RCP documents do need to be tailored to the organisation in question, it would appear, based on the information I have been provided with, that something well below an “emergency response” can be provided in this hospital, and perhaps also the wider private sector. RCP guidelines clearly require “emergency assessment by a team with critical care competencies”. The escalation policy at Ramsay Healthcare hospitals currently (for a patient scoring 7 or above) is for the registered nurse “to immediately inform the RMO and named consultant. The named consultant to attend urgently and review the patient and agree action to be taken. Consider transfer of care to a level 2 or 3 clinical care facility i.e. HDU or ICU”. This policy clearly anticipates initial review by a consultant, outside the hospital, who may well not be available to attend on an emergency basis. (2) We heard evidence that Berkshire Independent Hospital has performed 5 operations like this between 2016 and 2018, including Simon’s operation. Whilst the surgeon had experience of the procedure in the NHS, post- operative management is carried out in a general ward, caring for patients from a range of specialities. Nursing staff in this context may well never have cared for a patient after this operation, and not be familiar with the signs and symptoms to be aware of and in particular, to alert clinical teams to signs which point towards leak and/or sepsis. I accept that private hospitals cannot realistically provide separate specialist wards for this. It does however raise the question of whether private hospitals should be carrying out procedures like this without specialised nurses and without facilities to escalate care without delay. (3) The final concern relates to Berkshire Independent Hospital only. The hospital investigation into these events was inadequate, particularly in r relation to the decision-making of the key player in this matter, There are 2 sentences in the report regarding his involvement, and it would appear, a simple acceptance of his view that this was no more than a recognised complication of this procedure. This organisation will not learn from sad cases like this if their own investigations are inadequate. We heard some evidence of review of this procedure, but I suggest that this is considered very carefully, to ensure that the risk of future deaths is reduced by adequate and candid investigation. 6. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe your organisation has the power to take such action. Classification: OFFICIAL-SENSITIVE -4- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st January 2019. 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 Simon’s family, and other Interested Persons form the Inquest. 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. 6th December 2018 Mrs Heidi J. Connor Senior Coroner for Berkshire Classification: OFFICIAL-SENSITIVE -5-
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.
ott, Independent Healthcare 6 Providers Network bd NHS CONFEDERATION e Foe Mrs Heidi Connor Senior Coroner Berkshire Coroner's Office Reading Town Hall Blagrave Street Reading, RG1 1QH By email only 31 January 2019 Dear Mrs Connor, INTRODUCTION | am writing in response to your Regulation 28 Report received in November 2018. Your report followed the inquest you conducted into the death of Simon Healey who was treated at the Berkshire Independent Hospital, part of Ramsay Health Care Group and a member of the Independent Healthcare Providers Network (IHPN). Our thoughts are with Simon Healey’s family during this difficult time. | note the context of your letter is that you consider it likely that some of the issues raised in this case would be relevant to a number of private healthcare providers. | also note that the issuing of a Regulation 28 Report is designed to bring information of a public safety concern to the attention of the recipient and is not punitive in nature. All IHPN Board members have been made aware of your letter to me in my capacity as Chief Executive of IHPN. The Chief Executives of the majority of independent sector corporate hospital providers are represented on the IHPN Board. In preparing this response IHPN has liaised with Ramsay Health Care UK who have been open in sharing their response with us and demonstrated their eagerness to contribute to sector learning. We will also be sharing this response with the Care Quality Commission (CQC) as part of our ongoing engagement programme. INDEPENDENT HEALTHCARE PROVIDERS NETWORK (IHPN) The Independent Healthcare Providers Network (IHPN) is the representative body for independent sector healthcare providers of services ranging through acute, primary, community, clinical home healthcare, diagnostics and dental. NHS Partners Network NHS Confederation, Floor 15 Portland House, Bressenden Place, London SW1E 5BH 020 7799 6666 nhspn@nrhsconfed.org www.nhspn.org NHS Confederation. Charity number 1090329. Company number 04358614. Registered address Floor 15, Portland House, Bressenden Place, London SW1E 5BH Independent Healthcare “ Providers Network e NHS CONFEDERATION e ®ee% IHPN is a voluntary membership body, and not a standards authority or regulator. Our three main areas of focus are advocacy and influencing on behalf of the sector; facilitating sharing, learning and networking opportunities for mernbers, and assisting with regulatory compliance. THE INDEPENDENT HEALTHCARE SECTOR Vrere are over 220 independent acute hospitals in England and many more specialist acute facilities. These hospitals provide a range of services to both private anc NHS patients. In the last year, independent hospitals carried out over 500,000 elective surgical procedures for NHS patients and many more for privately funced or insured patients. IHPN members treat over 05% of all patients treated in the independant healthcare sector. Safety is the number one priority for all [HPN members as safe care is the bedrock of an effective healthcare provider. independent hospitals have a strong track recard of delivering safe, high quality care. Patients are positive about the care they receive. Over the past year, 99% of inpatients said that they would recommend independent sector services to friends and family’. 9 of the top 10 providers under Patient Reported Outcome Measures (PROMs) scores for primary hip replacements are from the independent sector (Oxford Hip score, measured by adjusted health gain)’. 73% of independent hospitals have an overail good or outstanding rating and 60% of independent hospitals are rated good or outstanding for safety, compared fo 33% of NHS hospitals”. There is good evidence that indepandert providers welcome opportunities and are committed to making improvements In care where changes are needed. As the CQC has stated, “Where we nave found problems, providers have been quick to take our findings on board and make improvements. Of the 13 locations thal we had re-inspecied as at 2 January 2018, all four of those initially rated as inadequate had improved; two of these are now rated as good”. This indicates that there is a strong culture within the sector not only to avoid poor performance but to deal with it decisively if it occurs. MATTERS OF CONCERN - 1 “? believe that the NEV/S policies in place at private hospitals should be reviewed, This relates not only to awareness of the policy and sepsis training generaily, but alse consideration of the arrangements for escalating care where a patient becomes critically unwell.” NEWS (National Early Warning Score) policies and scoring for patient assessment have been implemented as standard across the independent healthcare sector since 2012 in line with the national NEWS role out. NHS England, with the support of NHS Improvement, are endorsing NEWS, and have launched an ambition to increase its use to 100% of acute and ambulance settings by March 2019. Independent providers are making good progress working towards that ambition. * NHS Engiand FTT inpatient data from Dec 17 to Nov 2018 ? Source: NHS Digital PROMs final data release covering April 2016 - March 2017. PROMs measure health gain in patients and this provides an indication of the outcomes or quality of care delivered to NHS patients and has been collected by all providers 0} of NHS~ funded care since ete 2009. 4 cac State of Care pt Independent Healthcare \ Providers Network & NES CONFEDERATION e Eee eS The COC’s Sie of care in ndenencent ecule hospla's published in Apri 2018 cid cle examples of inconsistent monitoring of risks and exarnples where effective escalation did not occur within providers. in order to address this and other quality related findings, IHPN began a learning programme with the COC to ensure that their view of whal makes for outstanding care in the Safe domain is fully understood throughout the sector so that best practice can be adopted across the board. IHPN’s formal engagement with the CQC includes frequent catch-up meetings to discuss quality themes across the sector. It also comprises joint COC-IHPN serninars where providers share best practice and learn from each other. Previous seminars have focused on safety and well-led. We will be discussing escalation policies in independent acute hospitals with the CQC in February. JHPN facilitates a Clinical Forum that brings together Directors of Clinical Governance, Chief Nurses and Medical Directors from across our membership. The prernise behind the forum Is that providers do not compete on safety and it has proved an excellent medium for members to share best practice and to learn from each other. IHPN has asked Ramsay Health Care to present their lessons learned from this case to the forum. in order to support this agenda item, IHPN will undertake a scoping exercise on how providers assure themselves of levels of staff awareness of NEWS and on sepsis training. This will assist us to identify if these two elements of this unfortunate case are indeed reflected across the wider sector. “Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant’s availability to attend and review the position” ... “something well below an “emergency response” can be provided in this hospital, and perhaps also the wider private sector.” inter-hospital transfers are a well embedded mechanism to ensure that patients are treated in the most appropriate place should unanticipated complications arise. These transfers take place between providers of all types — from NHS providers to other NHS providers, frorn independent providers to indepencent providers, and from independent providers to NHS providers and vice versa. A transfer does not mean that care has not been appropriately provided in the originating hospital. Nelther does it mean that a patient should not have been admitted to the originating hospital in the first place. Independent hospitals, like NHS provicers, undertake robust pre-admission processes to establish that they are an environment in which a patient can be safely treated. Unanticipated deterioration in the condition of patients is a factor in all healthcare settings and so the right response is to have plans in piace to deal with it when it occurs. Some independent sector providers do also have higher acuity facilities including intensive care and high dependency units. itis nof the case that NHS providers are the sole option when patients need to be transferred to a different setting from an independent provider and some independent hospitals receive more emergency transfers than they transfer out. We are not aware of any evidence to suggest that transfers of patients are particularly associated with providers who do not have intensive care facilities, such as NHS community and district general hospitals, mental health inpatient units and some independent sector hospitais. The NICE guidelines on patient transfers do not suggest that patients should only be treated where there are Independent Healthcare & Providers Network ° NHS CONFEDERATION 6 Se g@® intensive or high dependency facilities an site. Instead the focus should be on ensuring that patients can be safely transferred under structured arrangements to the right place should they require a higher aculty of care. itis clear from the CQC’s end of programme report that more work needs to be done to formalise ihe arrangements some independent providers have in place to ceal with celeriorating pallents and we have strongly encouraged all providers to have formal Service Level Agreements in place with neighbouring healthcare providers able to provide higher acuity care in the event of a patient's health deteriorating unexpectedly. However, we are confident that the overall picture for the sector is good. |HPN members already nave clear processes in place to manage deterioration and, where necessary, to arrange ihe transier of patients to higher acully settings. IHPN recognises that your concerns point to a broader national picture. A report of the HSIB (Healthcare Safety investigation Board) published earher this month highlights a lack of consistent guidelines or structured national guidance to ald doctors when transferring critically i] patients to specialist units, following the death of a man being transferred from an NHS district general hospital to a tertiary centre. There are increasing numbers of emergency inter hospital transfers in the NHS as the NHS separates cold elective sites from hot acute sites - cold sites offen do not have high acuity ITUs. Our own research found that in 2017, the percentage of independent hospitals’ total NHS and private caseload that resulted in an emergency transfer to the NHS was just 0.12% of inpatient admissions. IHPN have approached the Department of Health and Social Care and the Association of Ambulance Chief Executives who are required fo formally respond to the safety recommendations of the above mentioned HSIB report and seek to ensure thal Independent providers are considered in the response. MATTER OF CONCERN ~ 2 “| accept that private hospitals cannot realistically provide separate specialist wards for this. If does however raise the question of whether private hospitals should be carrying out procedures like this without specialised nurses and without facilities to escalate care without delay.” IHPN’s view echoes that of Ramsay Health Care UK’s as set out in their own response to you as follows: “RAMSAY, the same as most other independent health care providers, cares for patients who are admitted for varying elective surgical procedures. These procedures may be in different craft groups and one of the best practice elements the independent sector can demonstrate is the care provided by trained muiti-skilled staff. These staff are skilled in caring for a variety of patients with a variety of conditions and surgical procedures. They develop skills in identifying post-operative complications and are trained in caring for the acutely ill patient; and gain competence (which is tested and assessed) in delivering care in many settings and for many patients with differing probiems.” We believe the competency of nursing staff in the independent sector is good and it is a strength rather than a weakness that nurses treat a greater range of acute patients in the independent sector, rather than specialising on a sub-set of patients. The CQC has found that patients in the independent sector receive a good continully of care, that staff morale is generally good and thal this has an impact on the care that people receive. independent Healthcare Providers Network NMS CONFEDERATION On a related point concerning nursing staff, healthcare systems across the UK have seen a culture change in recent years, with a shift to more openness, transparency, good practice around whistleblowing, and a speak-up culture. Most independent providers have a dedicated person(s} appointed as a Freedom to Speak Up Guardian. Providers have whistleblowing policies anc orovide mandatory training to staff on whistleblowing and raising concerns. Independent providers also adhere to the Duty of Candour regulation. HPN has invited eaeramaien CQC’'s National Guardian, to attend our Clinical Forum on 34 January to further raise the profile of Freecom to Speak Up Guardians in the independent sector. CONCLUSION | hope that the above addresses the concerns you have raised and assures you of the actions IHPN is taking, to facilitate learning across the independent healthcare sector from this sad event. Yours sincerely, Tye David Hare Chief Executive independent Healthcare Providers Network
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