Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0024, written 21 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 | 21 Jan 2019 |
|---|---|
| Reference | 2019-0024 |
| Deceased | Neil Black |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation Trust · Birmingham Community Healthcare 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: 1. Birmingham Community Healthcare NHS Foundation Trust 2. Birmingham and Solihull Mental Health NHS Foundation Trust 1 CORONER I am Louise Hunt Senior 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 06/04/2018 I commenced an investigation into the death of Neil Antony Black. The investigation concluded at the end of an inquest on 18th January 2019. The conclusion of the inquest was: Drug related; illicit drug use. Inconsistent and infrequent physical observations; inadequate interaction between prison healthcare teams resulting in a delay in receiving appropriate treatment and a lack of a clear policy for observations undertaken on prisoners going through the detoxification process contributed to Mr Black's death. 4 CIRCUMSTANCES OF THE DEATH Neil Antony Black was remanded into HMP Birmingham on 8th March 2018. On arrival to prison he was assessed by prison and nursing staff where he disclosed extensive alcohol and IV drug use. He was remotely prescribed detoxification treatment, which included several medications and a schedule of twice daily observations for five days to support and monitor his withdrawal from IV drug use. Neil disclosed that he was suffering with a DVT in his right leg. This was not examined by nursing or medical staff. He was also observed to be limping at this point. Neil's observations were irregular and inconsistent, sometimes not completed at all due to the prison being in 'night state' and equipment was not always readily accessible. Despite Neil disclosing his DVT on his arrival, his GP consultation on 9th March did not result in an examination of his leg. Neil was seen on the morning of 10th March looking unwell by IDTS nurses. He did not want his blood pressure taken and no other physical observations were recorded. There is no record of Neil being seen again by nursing staff or medical staff that day despite presenting as unwell. He was also seen by prison staff limping and was not eating meals. He was observed sleeping in his cell at 00.25 on 11th March but no physical observations were taken. Neil was next seen at 10.28 on 11 March, appearing to now be very unwell, dehydrated and was struggling to stand and support himself. The IDTS nurse referred her concerns to the primary care nurses as recorded in system 1 notes. They advised her to continue to push fluids but did not go to examine Neil themselves. The IDTS nurse returned to see Neil in his cell where she completed the expected observations. He was seen again later by another IDTS nurse and continued to appear visibly very unwell. His heart rate was very high; he was hot, sweaty and said how unwell he felt, the nurse recorded concerns for a potential pulmonary embolism. The IDTS nurse referred her concerns to senior primary care nurses in person rather than through hotel 2 emergency call. The primary care nurses failed to go to examine Neil and relayed incorrect medical information to the IDTS nurse requesting support. Neil was not seen at all overnight and his first observations on 12 March showed a significant deterioration in his physical condition. Oxygen saturation levels were taken for the first time at this point and were extremely low. A hotel 2 call was made requesting urgent assistance. This led to an ambulance be in called upon GP's advice. The primary care nurses who responded to the hotel 2 call suspected sepsis immediately. He was admitted via ambulance to City Hospital. Appropriate sepsis treatment started as per hospital policy and initially Neil responded well to this treatment. Extensive testing and screening took place revealing a diagnosis of infective endocarditis and lung abscesses. He started to rapidly deteriorate and was admitted to ITU where he was later mechanically ventilated for respiratory failure. Further deterioration led to multi-organ failure and Neil passed away on 31st March at 12.51. Following a post mortem the medical cause of death was determined to be: 1a 1b MULTI-ORGAN FAILURE SEPTIC SHOCK DUE TO STREPTOCOCCAL SEPTICAEMIA, LUNG ABSCESSES, EMPYEMA AND ENDOCARDITIS. INFECTED DEEP VEIN THROMBOSIS, PULMONARY EMBOLUS INTRAVENOUS DRUG USE 1c 1d 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. B wing is the drug detoxification wing at Birmingham prison. Prisoners undergoing drug detoxification see IDTS nurses for drug needs and primary care nurses for health care needs. Prisoners on B wing often have complex mixed needs. The evidence at the inquest confirmed there were no joint handovers despite the nurses being located very close to each other. Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach. 2. Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses. IN addition witnesses were unclear who should undertake what observations on prisoners and for what reason. Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations. 3. Neil Black came into prison with a DVT in his right leg which was caused by IV drug use injecting into his groins. His groins sites and leg were not examined during his time at the prison. Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites. 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 18 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family G4S I have also sent it to NHS England, CQC and the Minister for Prisons 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 21/01/2019 Signature Louise Hunt Senior 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.
INHS| Birmingham Community Healthcare NHS Foundation Trust 15 March 2019 Chief Executive Officer Trust Headquarters Private and Confidential 3 Priestley Wharf HM Senior Coroner, Mrs Hunt Holt Street Birmingham Coroner’s Court Birmingham Science Park 50 Newton Street Aston Birmingham Birmingham B4 6NE B7 4BN Tel: 0121 466 7010 Fax: 0121 466 7001 Email: Dear Mrs Hunt Response to Regulation 28 Report to Prevent Future Death dated 21 January 2019 Inquest touching the death of Neil Antony Black: 15-17 January 2019 Thank you for your Regulation 28 report relating to the death of Mr Neil Antony Black which we received from your office on 21 January 2019. Please do be assured that we have taken your concerns and findings very seriously. We note that actions are required to be delivered by both Birmingham and Solihull Mental Health NHS Foundation Trust (‘BSMH”) and Birmingham Community Healthcare NHS Foundation Trust (“BCHC’). This is a joint response. The MATTERS OF CONCERN are as follows: 1. B wing is the drug detoxification wing at Birmingham prison. Prisoners undergoing drug detoxification see IDTS nurses for drug needs and primary care nurses for health care needs. Prisoners on B wing often have complex mixed needs. The evidence at the inquest confirmed there were no joint handovers despite the nurses being located very close to each other. Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach. 2. Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses. IN addition witnesses were unclear who should undertake what observations on prisoners and for what reason. Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations. © 4 one. AY €3& disability j y Better Care: Healthier Communities E363 confident EMPLOYER 3. Neil Black came into prison with a DVT in his right leg which was caused by IV drug use injecting into his groins. His groins sites and leg were not examined during his time at the prison. Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites. This joint response by BCHC and BSMH has been prepared with the assistance of the Head of Healthcare at HMP Birmingham who holds that position jointly on behalf of both Trusts. BCHC and BSMH have agreed the following: 1. JOINT HANDOVERS We commenced a process on 11 February 2019 whereby the Nurse in Charge for both the “B3” team (the primary, or physical, healthcare team employed by BCHC) and the “IDTS” team (the Integrated Drug Treatment Service team employed by BSMH) have a verbal handover at the midday handover for any patients who are presenting as requiring joint care for both physical care and substance misuse treatment. The handover documents for both IDTS and B3 will be amended to ensure these patients discussed are recorded. This will be audited after one month to ensure the process is effective and any amendments to this process will be made. 2. IMPROVING THE RELATIONSHIP BETWEEN THE TEAMS AND PROTOCOL FOR OBSERVATONS (a) Relationship between the teams. Whilst we acknowledge there are challenges in the teams working relationships we can also cite a number of good practices and inter team working that we have initiated over the last year. We hold a Management/Leaders meeting every Monday morning where any issues are aired and can be immediately resolved to ensure problems are rapidly discussed and solutions implemented. To further improve the teams working together we have established a Band 7 (Team Manager) meeting for all healthcare teams on a monthly basis. This meeting will provide an opportunity where any issues between the healthcare teams can be openly discussed and resolutions agreed at an appropriately senior level. We have also planned a series of more informal events to support inter team working — these include “case busting” and team briefings. We will liaise with each Trust’s Organisational Development Team to review if additional Organisation Development work would be beneficial. (b) Protocol for Observations In relation to the physical observations there is a new protocol which clarifies the process for physical observations on prisoners. IDTS nurses complete observations for people at tisk of withdrawal which ensures people are experiencing a safe detoxification. IDTS also now complete the National Early Warning Score (NEWS) observation which results in a score and indicates the frequency of physical observations required (which IDTS continue to do). The NEWS score also indicates if any referral needs to be made to the “B3” physical care team or GP and provides a process to escalate concerns of a deteriorating patient. Physical care nurses from B3 are responsible for taken a full set of physical observations if any patient is referred to their team. The requirement to do this was sent out to staff on 11 February 2019. 3. PROTOCOL FOR EXAMINATIONS OF INJECTION SITES AND DVT SITES We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out. We would like to thank you for drawing this matter to our attention and sincerely hope that the controls outlined above will help to prevent future deaths of this nature. This response has been approved by John Short, CEO, Birmingham and Solihull Mental Health NHS Foundation Trust. Yours sincerely x Richard Kirby Chief Executive Officer Birmingham Community Healthcare NHS Foundation Trust Copies John Short, CEO, BSMH Head of Healthcare, HMP Birmingham Legal Services Departments, BSMH and BCHC
See every Prevention of Future Deaths report matching Birmingham and Solihull Mental Health NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.