Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0007, written 10 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2019 |
|---|---|
| Reference | 2019-0007 |
| Deceased | Malcolm Shaw |
| Coroner | Christopher Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Helen Thompson, Interim Chief Executive, Stockport NHS Foundation Trust, Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport, SK2 7JE CORONER lam Chris Morris, Area Coroner for Manchester South. 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 8" March 2018, | opened an inquest into the death of Mr Malcolm Marshall Shaw, who died at Stepping Hill Hospital, Stockport on 20" February 2018 aged 82 years. The investigation concluded at the end of the inquest which | heard on 20" August 2018 and 2 January 2019. At the end of the inquest, | recorded a narrative conclusion that Mr Shaw died as a consequence of injuries sustained in a fall which occurred whilst he was unobserved. His death was contributed to by underlying lung disease. CIRCUMASTANCES OF THE DEATH Mr Shaw was admitted to Stepping Hill Hospital on 10 February 2018 as a consequence of a general decline in his condition and hyponatraemia, for which he received treatment on the Acute Medical Unit. Investigations undertaken whilst on the Acute Medical Unit included a CT scan which showed evidence of Chronic Obstructive Airway Disease. In view of Mr Shaw’s medical history together with a raised Troponin level and new changes on an ECG undertaken on the Acute Medical Unit, a decision was made to admit Mr Shaw to ward A3, a cardiology ward. Mr Shaw was transferred to ward A3 late on the evening of 13" February 2018. On transfer to ward A3, Mr Shaw was noted to be confused and agitated, something which continued throughout the night. At some point between 06:00 and 06:35 on 14" February 2018, Mr Shaw sustained a fall on ward A3 which was not observed by any of the staff on duty. Whilst it was not initially thought Mr Shaw had sustained serious injury in the fall, on 15" February 2018, his right leg was noted to be shortened and rotated by the cardiology Senior House Officer. An X-Ray was then taken which confirmed that Mr Shaw had suffered a fracture to his right femur, in all probability as a result of the fall on the ward the previous day. Mr Shaw was referred to the Orthopaedic Surgeons, who listed him for surgery which was planned to take place on 17" February 2018 subject to optimisation of his condition. He was reviewed by a Consultant Anaesthetist on 16" February 2018 who considered he was fit for surgery, notwithstanding an operation would be high risk. When reviewed again on the day of surgery, it became apparent Mr Shaw's condition had deteriorated dramatically, and surgery was deferred. He was diagnosed with bronchopneumonia and died on 20" February 2018. A post mortem examination was performed following Mr Shaw’s death which confirmed he died as a consequence of:- la Bronchopneumonia b Chronic Obstructive Airways Disease and Immobilisation following fractured right femur 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. — In view of the fundamental importance of rigorous patient safety investigations whose conclusions are capable of withstanding logical analysis to improving care, it is a matter of concern that the Trust’s original investigation into the circumstances of Mr Shaw’s fall (which had presumably passed through the Trust’s own quality assurance mechanisms) was manifestly and fundamentally flawed. Whilst the court heard evidence of significant improvements the Trust has made to the way it undertakes investigations, it is a matter of residual concern that the organisation has yet to launch a revised programme of investigation training for those who undertake patient safety investigations. Specifically in relation to cases involving falls, it remains of concern that frontline staff do not appear to have been provided with any guidance as to how to capture the best available evidence as to the circumstances of the fall as soon as reasonably possible after the incident. This is a matter of particular concern bearing in mind the potential benefits such an approach would bring to the Trust’s ongoing efforts to understand the causes of falls on wards with a view to trying to prevent as many of them as possible. ACTION SHOULD BE TAKEN (In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 7'* March 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 COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to on behalf of Mr Shaws family. | have also sent a copy to of Hill Dickinson LLP, solicitors to the Trust. | have sent a copy of my report to the Care Quality Commission, and the Healthcare Safety investigation Branch who may find it useful or of interest. |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: 10" January 2019. Signature: Chris Mor Area Coroner, Manchester South.
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.
7th March 2019 Mr C. Morris H. M. Area Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris Mr H Mullen Deputy Chief Executive/Director of Strategy & Planning Oak House Stepping Hill Hospital Poplar Grove Stockport SK2 7JE Telephone: 0161 483 1010 Direct line: E-mail: Re: Prevention of Future Deaths: Inquest into the death of Mr Malcolm Marshall Shaw I am writing in response to concerns raised in your letter dated 10 January 2019 which we received following the inquest into the death of Mr Malcolm Marshall Shaw held on 2 January 2019. In your letter information was requested in relation to two matters of concern which arose during the inquest. The launch of the revised programme of investigation training for those who undertake patient safety investigations I can confirm that programme of investigation training has been developed and launched. We have the following programme in place: Quarterly Root Cause Analysis training, delivered by the Trust’s Quality Governance Team. This has been in place for a number of years In September 2018 the Trust introduced training sessions with an in-depth focus on statement gathering and writing. In February 2019, we have launched a revision to the training provisioin. Earlier last year the Trust had recognised that it was heavily reliant on a small team in undertaking and leading on patient safety investigations and therefore widened participation to include other staff. In February 2019 the Trust has implemented a check list to be completed at the time the panel meet to hear the final investigation report. The check list, advocated as best practice by NHS Improvement, supports the Executive Director in identifying if the key requirements for a good investigation have been met during the investigation. The checklist includes identification of the training status of the investigation team; that is whether they have received appropriate training. A training session is to be held with the Executive Directors on 12 March 2019, this will support consistency of overview and scrutiny of investigations. The Trust always ensures that an appropriately trained person leads or facilitates the investigation team when they undertake an investigation into a patient safety incident. I understand that during the inquest Chief Nurse & Director of Quality Governance, explained that in line with the Trust’s Quality Governance Framework, a considerable amount of work had already happened to address the issue of consistency in investigations, some of this work is described above. Frontline staff do not appear to have been provided with any guidance as to how to capture the best evidence as to the circumstances of the fall as soon as reasonably possible after the incident I understand that fall to support staff in these situations. These have been expanded on further, and include: was able to describe some of the actions put in place since Mr Shaw’s Earlier last year the Trust developed a specific methodology aimed to support quality improvements, this is called the Patient Safety Collaborative approach and is widely recognised in the NHS as best practice. In June 2018 the Trust launched a Safer Mobility Collaborative aimed at reducing inpatient falls by March 2019. Part of the collaborative included the launch of an immediate assessment of the circumstances of the fall, taking statements from staff and talking with the patient to assess that all actions to ensure patient safety are in place. In January 2019, the Trust further enhanced its approaches to monitoring falls via our Quality Safety Leadership Summit, held three times a week. At this meeting, senior nurses are able to ensure that full investigations have started and include immediate statements. The Trust is pleased to report that it continues to be on target to reduce the number of falls within the organisation. I trust that the information provided above is satisfactory to you, please do not hesitate to contact us if you require any clarification. Yours sincerely Hugh Mullen DEPUTY CHIEF EXECUTIVE DIRECTOR OF STRATEGY & PLANNING Page 2 of 2
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