Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0049, written 14 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Feb 2019 |
|---|---|
| Reference | 2019-0049 |
| Deceased | Kenneth Whittington |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner : BRIGHTON for the City of Brighton & Hove BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047 GILVA D.J.TISSHAW, BA(LAW)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Dame Marianne Griffiths, Chief Executive, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, ighton Consultant General & Colorectal Surgeon, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton Deputy Medical Director and Safety and Quality onsuitant in Intensive Care and Anaesthetics, Brighton and Sussex Universit pitals NHS Trust, Royal Sussex County Hospital 4, meal... of Medico-legal Services, Brighton and Sussex niversity Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton 2. 3. CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove . 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. INVESTIGATION and INQUEST On 14" June 2018 | commenced an investigation into the death of Kenneth George Alfred WHITTINGTON. The investigation concluded at the end of the inquest on 6" February 2019.The conclusion of the inquest was NARRATIVE CONCLUSION — PLEASE SEE ATTACHED SHEET. CIRCUMSTANCES OF THE DEATH See Record of Inquest VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner : BRIGHTON for the City of Brighton & Hove : BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047 GILVA D.J.TISSHAW, BA(LAW)HONS 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) Mr. Whittington’s initial operation was abandoned because on his pre operation assessment on the 23 March 2018 there was no Junior Doctor present. It became apparent that the presence of a Junior Doctor was not imperative by any means. | gather that since this situation occurred and caused a delay in Mr. Whittington’s operation the presence of a Junior Doctor in these circumstances is really no longer required. Although the delay neither caused nor contributed to Mr. Whittington’s death it must nonetheless have caused him considerable anxiety and inconvenience. . (2) Most importantly post operation ‘paperwork’ contained no instructions regarding the management of his urinary catheter or how long it was to remain in situ. a <2: that he had expected to be in place for at least two weeks post operatively and very likely longer because at the operation he had had to make a bladder repair and therefore did not want to remove the urinary catheter until such time as the bladder had healed. Had he made this requirement clear | have no doubt that this matter would not have come to Inquest. (3) Immediately post operatively Mr. Whittington’s epidural became disconnected. He complained of increasing pain over the ensuing night and in spite of this nobody, not even the most senior Nurses, ever checked his epidural!. It was not until some hours later in the early morning that the cause for his increasing pain was ascertained. At that stage his pain control was optimised however, this is not a situation which should have occurred. During his period of increased pain he developed a pneumonia. (4) Following the operation Mr. Whittington’s last contact with his Consultant was immediately post operatively. Due to the system operated at the Royal Sussex County Hospital (along with many other hospitals as | understand it) the situation is that the operative surgeon will not see the patient again unless there is some specific reason to do so. ‘ Instead the patient will be seen by the on call surgical team for that particular __|____day or part of the day. VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LL.B. . WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047 GILVA D,J.TISSHA W, BA(LAW)HONS Mr. Whittington therefore saw a Consultant who did not know him and who did not understand either the condition that Mr. Whittington had come in to hospital with (Colovesical Fistula) or the fact that he needed an operation which had included a bladder repair as | have already pointed out (2 above). The surgeon wanted the urinary catheter to remain in situ for at least two weeks to allow the bladder repair that had been made at Mr. Whittington’s operation to heal. . This was absolutely crucial and yet no specific instructions were given and the post-operative pathway which was being followed gave very little help in that respect either, save to suggest that the catheter should always be removed early, well prior to discharge. Had there been. post-operative instructions and had there been a checklist for the Consultant picking up the ward rounds following the operation, the catheter would not have been removed and Mr. Whittington would not have died. If the Trust is insistent on perpetuating this lack of continuity between the Surgeon and the post-operative Consultant care there must be sufficient handover and sufficient clear instructions from the Surgeon doing the operation as to the post-operative care so as to protect the patient. (5) On the 2" May Mr Whittington’s haemoglobin was low. Mr. Whittington needed and was written up to receive two units of blood on the 2" May. In fact he received one unit on the 3% May. There is absolutely no rationale for what happened or exploration thereof. This is unsatisfactory ~ (6) Mr. Whittington was due to be discharged on the 4" May. His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 May 2019. |, the coroner may extend the period. Your response must contain details of action taken or proposed to be taken, setting 3 VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE LLB, WOODVALE, LEWES ROAD Her Majesty’s Senior Coroner BRIGHTON for the City of Brighton & Hove BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 CATHARINE PALMER LL.B (HONS) ° Fax: Brighton (01273) 292047 GILVA D.J].TISSHAW, BA(LAW)HONS ~ r out the timetable for action. Otherwise you must explain why no action is proposed. —t 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons ena 4. Secretary of State for Health, Department of Health 5. Simon Stevens, Chief Executive, NHS England 6. Clinical Commissioning Group | 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 Date: 14" February 2019 SIGNED BY: Vsfanc fencing. Senior Coroner Brighton and Hove
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.
INAS: Brighton and Sussex University Hospitals NHS Trust Your ref. VHD/ST/MWhittington Our Ref: RS/INQ/18/68 3 May 2019 Miss Veronica Hamilton-Deeley Brighton & Sussex University Hospitais HM Senior Coroner for Brighton & Hove NHS Trust The Coroner's Office Trust Headquarters Woodvale Royal Sussex County Hospital Lewes Road Eastern Road Brighton Brighton BN2 3QB : BN2 5BE Dear Miss Hamilton-Deeley The Late Kenneth Whittington Thank you for your letter of 14 February 2019 enclosing your Regulation 28 report, Record of Inquest, and for sharing your concerns. We have acted on your concerns, have learnt from Mr Whittington’s inquest, and | am pleased to say we have made improvements to our services which | will summarise below. Firstly | wish to offer my heartfelt condolences to Mr Whittington’s family and friends. The findings from the inquest have been shared widely within the Trust and have been discussed at the Safety Huddle attended by the Medical Director and Nursing Director, the Serious Incident Review Group meeting and the Division of Surgery’s governance meetings. This has ensured senior ownership to review the systems and processes in place, make the necessary changes, and ensure the learning is filtered through to all levels of staffing within the Trust. , The i itera ing the learning and improvements following the inquest have been led b Chief of Service for the Division of | Consultant Governance Lead for Surgery, and iE Directorate Lead Nurse has been in contact with Mr Whittington’s family as part of the process and will continue to provide them with support and information. There was no junior doctor present at the pre operative assessment appointment to see Mr Whittington. This resulted in his atypical antibodies not being identified and therefore the surgery did not take place on the original date planned. For this | apologise. A General Medical Council (GMC) and Health Education England Kent Surrey and Sussex (HEEKSS) Deanery review of the Digestive Diseases Directorate in the Trust was undertaken. This review was critical of our use of junior doctors in pre-operative assessment processes and they recommended that these tasks should be nurse delivered as is the case in most NHS Trusts now. A Working Group was convened to change the pre operative assessment process and a new model is being developed. Nursing Staff are responsible for flagging pre operative abnormal blood test results. Mr Threlfall is in contact with the Pre Operative INAS: Brighton and Sussex University Hospitals NHS Trust Assessment Manager and the Perioperative Directorate Lead Nurse and this work is on- going to maximise efficiency and safety. The documentation in Mr Whittington’s records was not to the level we would expect. As a result, [MB has fed on a piece of work to ensure the general surgeons will use an electronic system (Bluespier) for recording operations. The sections of the operation note mandated by the Royal College of Surgeons can be easily filled in on the computer to generate a typed operation note in clear, legible print. A section for post-operative instructions is included on Bluespier. This means the operation note and post operative instructions are recorded electronically making it easier for all staff to access and read. This can be printed and added to the paper records. In addition, the Division of Surgery have reviewed the Enhanced Recovery Programme booklet and have amended this to include a section on the management of post operative ‘urinary catheters. An order for the amended booklets has been placed with the printers. When the new booklets have been printed we will roll these out for use. To strengthen awareness and recording, the daily ward round sheets now include a pre printed prompt on urinary catheters. An audit is underway of documentation in surgery measured against National Guidelines| is leading on this audit. Our practice has changed and Nursing staff no longer remove urinary catheters on the Surgical wards, without clear documented instruction in the records from the doctors to do so. The Senior Nurses are also conducting an audit to focus on the quality of the Level 9A nursing documentation, these results will be shared with the Clinical Governance meeting in the Division of Surgery for action as necessary dependent on the results. Wendy Caddye, Nurse Consultant for Pain Management, has reviewed and revised the Trust’s Epidural Policy to provide robust and clear guidance for all staff on the management of disconnected and failed epidurals. A section has been added to the policy titled epidural failure. To supplement this, all Level 9A nurses have attended, or are in the process of booking to attend, an Acute Pain Study Day which includes specific training on epidural management. All nurses in charge of a shift on the ward are fully epidural trained. We do operate a system of a consultant surgeon being the consultant for the week, this allows us to ensure our patients are seen by a consultant each day. To improve continuity of care and ensure the team are aware of each patient on the ward, on 25 February 2019 we introduced mandatory Board Rounds to take place in the morning, before the ward rounds, on all wards and in all specialities to facilitate improved communication between ward teams (doctors, nurses and allied health professionals). The principles of the Board Round are to confirm the patient acuity (how unwell they are), have they had any test results which require review, do they need any tests to progress their care, what interventions/actions need to be taken and when e.g. removal of catheter. The meeting occurs every morning. Actions are recorded on an Electronic Whiteboard and are followed up by the Nurse in Charge that day. Feedback from staff about the daily Board Rounds indicates that this has facilitated improved communication between all healthcare professionals at all levels on Level 9A. The surgical team also have a 4pm review meeting each day. The purpose of the meeting is to review and complete any outstanding actions and prepare a clear and thorough handover for the surgical team covering the night shift. The rationale for any changes in the plan will then be documented in the patient's records. | agree, the documentation in Mr Whittington’s case NHS: Brighton and Sussex University Hospitals . ° NHS Trust in this regard was not good enough. The importance of good clear record keeping has been reinforced at the Ward Huddles and at the Clinical Governance meeting. We continually strive to improve the quality of our documentation and the audit results will drive this improvement on an on-going basis. Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation. Where any individual nurse’s documentation is found not to be the level and quality expected, the Ward Manager and Matron will address this with the individual nurse. The above is a summary of the actions we have taken following the inquest and your Regulation 28 Report, | hope you feel assured by the improvements we have made to our systems and processes. | am confident these improvements have increased the safety of our patients and staff. Finally, | would just like to reiterate my condolences to Mr Whittington’s family and friends on behalf of the Trust. Yours sincerely Dr George Findlay Chief Medical Officer and Deputy Chief Executive
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