Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0117, written 1 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2019 |
|---|---|
| Reference | 2019-0117 |
| Deceased | Alexander Green |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal United Hospitals Bath NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 1st April 2019 REF: 8036 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: James Scott Chief Executive Royal United Hospital Bath CORONER lam M E Voisin Senior Coroner for Area of Avon 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. tp://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 25/10/2017 | commenced an investigation into the death of Alexander Frederick Richard GREEN. The investigation concluded at the end of the inquest 29th March 2019. The conclusion of the inquest was Accident contributed to by neglect CIRCUMSTANCES OF THE DEATH Alexander Green died on 3rd October 2017 at Southmead Hospital, Westbury-on-Trym, Bristol. On 30th September 2017 he was out for a night socialising with friends and was seen to fall. Around 1 hour later at 03.59hrs an ambulance was called when Alex was found lying in the road by passers-by. He was taken Royal United Hospital, Bath and was handed over as intoxicated; his Glasgow Coma Score was 13/15 but he was not seen until 07.20hrs by a doctor who did not diagnose his head injury. Instead Alex was handed over as intoxicated. Alex was not reviewed again that morning by a doctor. At 14.05hrs he suffered a respiratory collapse; a significant head injury was diagnosed which included a fractured skull and haematoma. He was transferred to Southmead Hospital where he underwent treatment; but due to the delay in diagnosis and transfer the treatment provided was futile. He died due to the injuries he suffered in a fall. Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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. The handover at around 8am resulted ina failure to challenge and communicate effectively. Handovers need to be considered across the whole of the trust not just the emergency department to ensure they are appropriate and effective. The reason | include this as a trust wide matter of concern is that | have recently dealt with another case where there were failures in the handover on another ward at the Royal United Hospital. | have been advised that other hospitals use the SBAR tool at handovers to assist in communication. 2. The NICE guideline for head injury was not considered appropriate for use in this case when it is clearly designed for exactly this case — you ascribe depressed conscious level to intoxication only after-a significant brain injury has been excluded. 3. There was an assumption by everyone managing Alex that he was intoxicated when in fact he had a significant head injury; SWAST | am told have developed training in relation to bias (and intoxication is included in that). Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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 28" May 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 | have sent a copy of my report to the chief coroner and to the following interested persons — the family of the deceased and South Western Ambulance Service. | 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. 01/04/2019 £6 Signature a ME VoisinSenior Coroner Area of Avon Telephone 01275 461920 Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
28th May 2019 HM Senior Coroner for Avon Coroner’s Court Old Weston Road Flax Bourton BS48 1UL Dear Madam Directors Office Royal United Hospital Combe Park Bath BA1 3NG Tel: www.ruh.nhs.uk Mr Alexander Frederick Richard Green - Response to Regulation 28 Report … Please see the Royal United Hospitals Bath NHS Foundation Trust’s response to the Regulation 28 Report issued on 1st April 2019. 1) Handovers need to be considered across the whole of the Trust to ensure they are appropriate and effective. Consider the use of the SBAR tool. The Medical Director has commissioned a working group with the Trust Medical Safety Lead to improve handovers through standardisation, education and training. This group reports into the Deteriorating Patient Steering Group, chaired by the Medical Director, with a focus on reducing avoidable harm. This is a Trust breakthrough Objective for 2019/20. There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched. The Emergency Department have taken the following steps: a) Patients who have not been referred to the Department will be allocated to an ED clinician who is anticipated (barring unforeseen circumstances) to be present in the Department for the entirety of the patient’s stay within ED. Thus minimising the number of occasions they will need to be handed over. b) An SBAR tool has been added to the Paediatric proforma used to facilitate safe handover between clinicians, specifically focusing on outstanding concerns and actions to be taken. c) The SBAR Tool has been incorporated into the verbal and written handover process between the nursing shift co-coordinator and ward staff. d) The SBAR Tool now forms part of the Observation Unit Passport completed for all patients transferred to the Observation Unit. 2) The NICE guideline for head injury was not considered appropriate for use when it is clearly designed for exactly this case – a depressed conscious level should only be ascribed to intoxication after a significant brain injury has been excluded. We are developing a tool that will assist and guide staff in safely excluding a brain injury in those patients who are believed to be intoxicated, that will strike the right balance between CT scanning those patients who need a scan and avoiding scanning those patients where a CT scan is only likely to cause potentially avoidable harm through exposure to radiation. It is envisaged that this tool will set out specific findings on an examination that might indicate a brain injury as opposed to intoxication, including a detailed step by step guide on how to carry out a thorough physical examination of a patient’s head. … For those patients in whom a significant head injury has been excluded and are diagnosed as being intoxicated, the Trust has developed a pathway to ensure that patients who fail to recover within the anticipated timeframe are reviewed by a senior doctor. This is to consider the possibility of an alternative diagnosis such as injury or illness not detected on initial assessment and to allow appropriate further investigations to be completed. 3) Assumption of intoxication – consider the development of training in relation to bias. Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers. … We trust that this response offers you sufficient assurances in relation to our actions following the Inquest into this tragic case. Yours sincerely James Scott Chief Executive
See every Prevention of Future Deaths report matching Royal United Hospitals Bath 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.