Prevention of Future Deaths reports · 2019

Brenda Gowan

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 report25 Feb 2019
Reference2019-0064
DeceasedBrenda Gowan
CoronerNadia Persaud
Coroner areaEast London
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

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

Responses

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.

Response from Barts Health NHS Trust (PDF)
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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