Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0064, written 25 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 | 25 Feb 2019 |
|---|---|
| Reference | 2019-0064 |
| Deceased | Brenda Gowan |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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East London Coroners MISS N PERSAUD SENIOR CORONER Waithamstow Coroner's Court Queens Road Walthamstow E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REF:7813 25" February 2019 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: a: Royal London Hospital, Whitechapel Road, Whitechapel, London E1 1BB 1 CORONER lam Miss N Persaud Senior Coroner for East London 2 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 3 INVESTIGATION and INQUEST On 05/01/2018 | commenced an investigation into the death of Brenda Kathleen GOWAN. The investigation concluded at the end of the inquest 21st February 2019. The conclusion of the inquest was a narrative conclusion: Brenda Gowan suffered a stroke on the 1 December 2017. She was discharged home for a trial period on 18 December 2017. At the time of discharge she was assessed as requiring 24 hour Supervision and was assessed as being at risk of falls. There was no professional care support provided during the night. Her family were not provided with advice as to how to manage the risk of falls at night. When her family reported a concern that Mrs Gowan was getting up a lot during the night, there was no documented reconsideration of the risk assessment or care plan. Mrs Gowan suffered a fall in her home address in the early hours of the morning, on the 23 December 2017. She sustained a catastrophic injury in this fall, from which she passed away. 4 CIRCUMSTANCES OF THE DEATH Brenda Gowan suffered a moderately severe stroke on the 1 December 2017. She was initially cared for on the Hyper Acute Stroke Unit at the Royal London Hospital. Her family describe the care at the Royal London Hospital as excellent. She was transferred to Whipps Cross Hospital on the 5 December 2017 for further medical care and rehabilitation. Her medical condition was relatively stable and her NIHSS score improved from 17 to 9. Her general condition however was far removed from her pre-stroke functioning. She was unable to communicate her needs; she was doubly incontinent; she had problems with balance and was at risk of falls. The possibility of an adverse outcome from falls was raised due to her lack of understanding of how to protect herself (e.g it is likely she would not have known to put her hands out to cushion her fall) and due to the prescription of clopidogrel. In hospital she had a full care plan in place to address the risk of falls. On 12 December 2017 a home visit was made with OT staff. It was identified that Brenda would need 24 hour supervision and that all of her care needs would need to be anticipated. Equipment was identified as being required, to include a falls detector. On 13 December 2017 a family meeting was held at the hospital. The family were provided with information from the medical, nursing, SALT and OT teams. The family were informed of the plan. There is no documentation about the family’s view relating to discharge. The family gave evidence that they made it clear at the meeting that they did not consider that Brenda was ready for discharge. They also did not consider that adequate arrangements were in place to allow a safe discharge. Brenda was discharged on 18 December 2017, for a “trial period”. Despite identifying that Brenda required 24 hour supervision, only 4 hours of care (broken into 4 visits) was provided. There were no care visits between 8pm to 8am. Brenda was noted to be at risk of falls during the night. No specific advice was provided to the family on how to address this risk. On the 19" December 2017 Brenda’s daughter called the hospital to report her concern that Brenda was getting up a lot during the night. The discharge plan had been based on Brenda being settled at night. There is no evidence that her risk assessment and care plan was reviewed in light of this concern raised by Brenda’s daughter. The recommended falls pendant had not been provided to the family. In the early hours of the 23 December 2017, Brenda had a fall near to her bed. From the position in which she was found, it is unlikely that Brenda cushioned her fall. Her face and head suffered a significant impact. ACT scan revealed a catastrophic intracranial bleed with significant mass effect and extensive facial fractures. Brenda passed away as a result of these injuries on the 23 December 2017. 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) Brenda was discharged home, less than 3 weeks after a moderately severe stroke, for a “trial period”. She required 24 hour supervision, but only 4 hours of social care was provided. Her family were expected to provide 20 hours of care. Her family did not consider that adequate steps had been taken to ensure that systems were in place to allow Brenda’s safe return home. The family were concerned about the amount of care support in place; the equipment required and the access to community services. There is no evidence that the family’s views were taken into account by the discharging team. (2)Brenda was at risk of falling at night. There is no evidence that the risk was fully assessed on discharge from hospital and no evidence of the family being provided with advice on how to manage the risk. (3)The discharge plan was based upon Brenda being settled at night time. When the family reported that this had changed and that Brenda was “up a lot” — the care plan for Brenda should have been re- considered. (4) There were no community support arrangements in place for the family to access, as the OT services had no contractual arrangement in place with Brenda’s registered GP. (5) The equipment required for managing the risk of falls had not been provided prior to Brenda’s fall (5 days after discharge from hospital). (6) There was no comprehensive plan in place address key aspects such as how care would be provided during the trial period. Such a plan could include the risks identified and how they were to be managed; the equipment required and ensuring that it was provided, installed and those providing the care trained in its use and ensuring that community support is available. Such a plan should be discussed with the community carers (family in this case) and key aspects agreed with them before discharge. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 237 April 2019. |, 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 ent a copy of my report to the Chief Coroner and to the following Interested Persons Il (representing the family) and to the CQC. | have also sent it to Mr Matthew Cole (Director of Public Health) 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. 25/02/2019 Signature Osh —— Miss N Persaud Senibr Coroner East London
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.
15th April 2019 PRIVATE & CONFIDENTIAL Ms Nadia Persaud HM Senior Coroner Walthamstow Coroners Court Queens Road Walthamstow London E17 8QP By Special Delivery Dear Ma’am, Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Telephone: Chief Medical Officer www.bartshealth.nhs.uk Re: Inquest touching the death of Brenda Kathleen Gowan I write in response to a Regulation 28, Report to Prevent Future Deaths, dated 25th February 2019, which was made at the conclusion of the inquest into the death of Brenda Kathleen Gowan. Barts Health NHS Trust takes Coronial investigations very seriously and I am sorry you have had to make Preventing Future Death recommendations and I am grateful to you for highlighting your concerns. Brenda Gowan was admitted to the Royal London Hospital following a stroke on 1st December 2017, and was transferred to Whipps Cross Hospital on 5th December. She was known to be at high risk of falls and was discharged with a care package on 18th December 2017. Mrs Gowan fell and sustained a catastrophic head injury causing her death on 23rd December. I note Brenda Gowan died from a catastrophic head injury due to a fall at home in the early hours of 23rd December 2017. You have raised a number of concerns relating to the discharge planning process received by Mrs Gowan and her family. The concerns you have raised in the Preventing Future Death report are: 1. Brenda was discharged from home, less than 3 weeks after a moderately severe stroke, for a “trial period”. She required 24 hour supervision, but only 4 hours of social care was provided. Her family were expected to provide 20 hours of care. Her family did not consider that adequate steps had been taken to ensure that systems were in place to allow Brenda’s safe return home. The family were concerned about the amount of care support in place; the equipment required and the access to community services. There was no evidence that the family’s views were taken into account by the discharging team. 2. Brenda was at risk of falling at night. There is no evidence that the risk was fully assessed on discharge from the hospital and no evidence of the family being provided with advice on how to manage the risk. 3. The discharge plan was based upon Brenda being settled at night time. When the family reported that this had changed and that Brenda was “up a lot” – the care plan for Brenda should have been reconsidered. 4. There were no community support arrangements in place for the family to access, as the OT services had no contractual arrangement in place with Brenda’s registered GP. 5. The equipment required for managing the risk of falls had not been provided prior to Brenda’s fall (5 days after discharge from hospital). 6. There was no comprehensive plan in place to address key aspects such as how care would be provided during the trial period. Such a plan could include the risks identified and how they were to be managed; the equipment required and ensuring that it was provided, installed and those providing the care trained in its use and ensuring that the community support is available. Such a plan should be discussed with the community carers (family in this case) and key aspects agreed with them before discharge We have investigated the above concerns and I can confirm: Following the concerns raised by the family in regards to feeling that they lacked choice and support during the discharge process, there has been a review of the communication and documentation following a Family Care Planning Meeting ensuring that there is signed understanding of the expectations and actions by all parties. This reformatted documentation will support accountability and be uploaded to the electronic notes system and a copy given to the patient and family. This will include all of the MDT (multidisciplinary team) looking after the said patient. The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available. Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway. Mrs Gowan’s family were ill-prepared for the task of providing the care for their mother outside of the time periods during which carers were supplied by Adult Social Care. The transition from hospital to home is recognized as a high risk period after such a life-changing event such as a stroke. Peace Ward will take steps to ensure that informal carers are given the opportunity to prepare. Firstly by ensuring the written documentation of care planning meetings are provided as described above. Secondly experiential training will be offered including the opportunity of a hospital stay with the patient to provide the care which will be required at home. This would include an overnight stay. The current provision of carer guidelines has been reviewed and will be included in the discharge information provided to the patient and family on leaving hospital as part of the discharge checklist. This will ensure that contact details in regards to onward referral and joint health and social care planning are accessible. We are however aware that the provision of responsive community care was not readily available for Mrs Gowan due to the limitations in stroke Early Supportive Discharge (ESD) provision at the time for Redbridge residents. Though a service does now exist, in order to ensure the safety of a patient requiring 24 hour supervision, Barts Health would not allow the discharge of such a patient without the acceptance from such a team and clear identification of risk mitigation. All of these changes will be reviewed within the monthly Stroke governance meeting for audit and re-evaluation. We can provide you with a copy of the Comprehensive Investigation report once it is completed upon request; this will highlight the areas that we as a Trust felt could be improved upon in future and the steps that we are taking to do so. I am once again grateful to you for bringing this case to my attention and I hope this letter fully answers the concerns you have raised. Yours sincerely Barts Health NHS Trust
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