Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0135A, written 24 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 | 24 Apr 2019 |
|---|---|
| Reference | 2019-0135A |
| Deceased | Ioannis Avgousti |
| 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. : WOCDVALE, 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, Brighton 2. Chairman, Brighton and Sussex University Hospital | Sussex County Hospital, Brighton , Medico-Legal Services Manager, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Brighton CORONER 1am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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. — 3 INVESTIGATION and INQUEST On 9" November 2018 | commenced an investigation into the death of loannis AVGOUSTI The investigation concluded at the end of the inquest on 18" April 2019.The conclusion of the inquest was NARRATIVE CONCLUSION — Please see attached sheet. 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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 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 taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: — (1) On the 2™ September 2017 the NICE Guidance for the Diagnosis and Management of Allergy was not followed. It was suggested to me that following the episode of anaphylaxis on the 27" July 2018 the NICE protocol was followed and therefore lessons had been learned to protect future patients however, | found that that was not the case. Whilst two Mast Cell Tryptase tests had been carried out and there had been some rather sporadic marking of a possibility of allergy in some of the hospital documentation, there had been no proper communication either immediately following the incident or later on within the hospital itself nor to the GP nor to Mr. Avgousti himself or his family. This was simply not good enough. (2) On the 6" October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. | saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) | found on the balance of probabilities that this set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET cail theni.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would | believe have been implemented, it would have been realised that he had an allergy to Co- Amoxiclav and he would have been given an appropriate alternative. Whilst | cannot say categorically that this would have been the case | believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6" October 2018. (3) On the same night the nurses and the doctors were working 12% hour “weekend” shifts”. The day nursing shift was one nurse short and so far as the doctors were concerned they were, as | understand they always are at weekends, too few in number and as a result all staff in hospital are thoroughly stretched and stressed and under resourced. This is no way to run a hospital service. Exacerbating factors in Mr. Avgousti’s case were that his rapid deterioration took place at around handover for both doctors and nurses, thus adding even more pressure to the situation. 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.LTISSHAW, BA(LAW)HONS 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 12" July 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Healys Solicitors - BE, Chair, Clinical Commission Group, Brighton 6. David Behan, Chief Executive, Care Quality Commission 7. Secretary of State for Health, Department of Health 8. Simon Stevens, Chief Executive, NHS England AROMA | 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. Date: 24" April 3618 SIGNED BY: . \ . TWanvilley. el HM Senior Coroner Brighton and Ho
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.
Your ref: VHD/ST/00955-2018 Our Ref: INQ/C9/18/142 9 July 2019 Miss Veronica Hamilton-Deeley HM Senior Coroner for Brighton and Hove The Coroner's Office Woodvale Lewes Road Brighton BN2 3QB NHS Brighton and Sussex University Hospitals NHS Trust Brighton and Sussex University Hospitals NHS Trust Trust Headquarters Royal Sussex County Hospital Eastern Road Brighton BN2 5BE Dear Miss Hamilton-Deeley The late loannis Avgousti Thank you for your letter of 24 April 2019 enclosing your report written under Paragraph 7, Schedule 5 of the Coroner's & Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (investigations) Regulations 2013, and the Record of Inquest. | note your conclusion that the reaction was not directly causative and was unlikely to have accelerated his death. | would however like to send my sympathies to Mr Avgousti’s family on behalf of the Trust and assure you and his family and friends that we have taken the learning from the inquest extremely seriously and my apologies and condolences go to his loving family and friends at this very difficult time. This letter is intended to demonstrate the learning and improvements we have made, some prior to the inquest, and some post inquest, to make the Trust safer for our patients, staff and visitors. Nice Guidance for the Diagnosis and Management of Allergy Head of Nursing for Quality Improvement has undertaken work in conjunction with the Pharmacy team to ensure that the Trust is fully compliant with these NICE quidelnes AAA hs confirmed that the Trust is currently compliant with most of the guidelines and has produced an action plan for the remaining guidelines. This includes a tool, to describe reactions and to determine actual allergy status, which has been developed and this tool will be incorporated into the new design of the Trust’s Prescription chart. The next print run of our newly designed Prescription charts will include: - Medication Name - Reaction - Decision tool to determine whether the medication is safe to administer to the patient concerned. We have redesigned our prescription charts. The Medication allergy status box has been moved to a new position on our new prescription charts so that it is continually visible to Brighton and Sussex University Hospitals NHS Trust prescribers and not obscured when the page is turned. The new charts are being printed and will be launched before the new intake of junior doctors. All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work. We have established a Penicillin Allergy sub-group of the Medicines Governance Group to keep the messages from Mr Avgousti’s inquest top priority in the minds of all our staff. Medicines reconciliation is now undertaken for every patient as soon as possible after they have been admitted to hospital. In relation to the non adherence to Trust policy, three Safety Alerts have been sent electronically to all staff to highlight the importance of Medicines Management and Safety. These include ‘Medicines Safety’ being a theme of the month; teams discuss the theme of the month at their daily safety huddles to keep the message fresh and to reach staff who may not have ready access to their emails. The ward nurses have also received refresher training and senior assessment on intravenous medication administration, this has been confirmed by the Ward Manager of Vallance ward. We have undertaken extensive investigation into the use of red allergy wrist bands, led by the Head of Nursing - Quality Improvement. We have conducted three audits of the appropriate use of red wristbands since January 2019 and there has been 10% improvement on compliance. In addition, our Acute Admissions Unit and Emergency Department are trialing a single coloured wristband system whereby if a patient has an allergy, they will only wear a red wristband with their details on it, and not an additional white wristband. The aim of this trial is to see if it reduces the risk of the red wristband not being seen when checking patients’ details prior to medication administration and our patients like Mr Avgousti who | gather did not like wearing multiple wristbands and would sometimes pull them off, being more comfortable and reducing the risk of removal. To supplement this trial, the Acute Admissions Unit team have put in a place a bespoke training programme for staff in order to highlight the risk of penicillin allergy and the use of co-amoxiclav. | am delighted to say that over the last month there have been no penicillin related incidents on the Acute Floor at the Royal Sussex County Hospital. These improvements will then be extended to other areas of the Trust. NEWS | agree with you that NEWS is a very important tool and should be used and followed correctly. | regret the NEWS documentation was not to the standard we expect. The ward team have reflected at length and the case was discussed by the wider team at the Medicine Division's Clinical Governance meeting on 17 May 2019. lam pleased to say, after a successful trial, the Trust has purchased an electronic system for recording NEWS and nursing assessments. This system is currently rolling out electronic recording of observations, the NEWS scores of all patients will therefore be available to view by the NHS Brighton and Sussex University Hospitals NHS Trust Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call. Staffing As confirmed at the inquest, there is a new Trust Guardian for Safe Working in post and there has been a review of current best practice for preventing fatigue and ensuring optimal performance of junior doctors to make sure we are in line with our peer organisations and are providing support and sufficient rest for our staff. Again | would like to extend my condolences and apologies to Mr Avgousti’s family and friends. | hope | have been able to effectively demonstrate the work we have undertaken to improve the systems and processes in place. We strive to continuously learn and improve and | feel sure that the learning from Mr Avgousti’s inquest has improved the systems in place. Finally, | will as' Head of Medico-legal Services, to bring a copy of our new prescription cha when they have been printed. Yours sincerely Dr George Findlay Chief Medical Officer and Deputy Chief Executive
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