Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0146, written 1 May 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 May 2019 |
|---|---|
| Reference | 2019-0146 |
| Deceased | James Fletcher |
| Coroner | Tim Holloway |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BLACKPOOL TEACHING HOSPITALS NHS FOUNDATION TRUST 1 CORONER I am Tim Holloway, Assistant Coroner for Blackpool & Fylde 2 CORONER’S LEGAL POWERS I 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 02/11/2018 I commenced an investigation into the death of James David FLETCHER (“the Deceased”). The investigation concluded at the end of the inquest on 29th April 2019. The conclusion of the inquest as to the medical cause of death was: 1a Peritonitis 1b Leak of gastric content 1c Feeding tube insertion (percutaneous endoscopic gastrostomy) 2 Cerebral palsy CIRCUMSTANCES OF THE DEATH 4 The Court reached a narrative conclusion as follows: James David Fletcher (“James”) was admitted to Blackpool Victoria Hospital, Whinney Heys Road, Blackpool (“the Hospital”) on 12th July 2018 for a percutaneous endoscopic gastrostomy (“PEG”) to be performed. His neurological diagnoses were quadriplegic cerebral palsy and epilepsy. He had other complications of his severe disability including chronic dislocation of the right elbow, dislocation of the left elbow joint which had required reconstructive surgery, gastro‐oesophageal reflux disease and reflux uropathy. He had a learning disability and was unable to communicate verbally. Whereas the surgery was uneventful, having been transferred to Ward 15b, a general surgical ward, his condition deteriorated post‐operatively. That deterioration was probably occasioned by a leak of stomach and small bowel contents through the wall of the stomach into the peritoneal cavity at the site of the insertion of the PEG tube into the stomach due to slow healing of the wound. That, in turn, gave rise to the development of chemical peritonitis, a rare but known complication of such surgery, which was established no later than the morning of 13th July 2018. The peritonitis caused ileus of the small bowel which led to small bowel obstruction which, in turn, occasioned repeated vomiting. The vomiting exacerbated the leakage of gastric contents by causing distension of the operative perforation at the site of the insertion of the tube into the stomach, thereby, in turn, exacerbating the peritonitis. No consideration was given to the possible presence of peritonitis and no imaging capable of positively identifying that condition was undertaken and thus the peritonitis went undetected prior to James’ death. On 14th July 2018, shortly after 11.08am, James died on Ward 15b of the Hospital on account of peritonitis due to leakage of gastric content. The PEG tube continued to be used in the period following the onset of the peritonitis. The use of the PEG tube was contraindicated. It is possible that this contributed more than minimally, negligibly or trivially to his death. Whereas broad spectrum antibiotics were not prescribed until 13th July 2018 it is not possible to conclude that this contributed more than minimally, negligibly or trivially to his death. Whereas there were admitted failures to carry out observations of vital signs in accordance with Trust protocol, to escalate James’ condition and to make clinical provision for him in accordance with Trust protocol even when elevated Early Warning Scores were identified and whereas there was a further admitted failure to monitor his fluid balance in accordance with Trust protocol it is not possible to conclude that these failures more than minimally, negligibly or trivially contributed to his death. CORONER’S CONCERNS 5 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) I am concerned that, whilst there exist policies concerned with the provision of care to those patients with learning disabilities there may be a lack of disseminated guidance and protocols for the care of those patients who are unable to communicate verbally. It is of particular concern that, in such cases, measures should be identified by which a method of communication can be established and/or appropriate measures should be put in place to compensate for any lack of communication verbally, including but not necessarily limited to the use of objective observations. 2) There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records. Whilst it is understood that “NEWS 2” is being introduced and supersedes the early warning score system being used at the time of the Deceased’s death and whilst the early warning score system in use at the time does not, therefore, form the subject matter of this report: a) I am concerned that the evidence revealed that substantial periods of time elapsed, at times measuring 9 or more hours, when no entry was made in the Deceased’s History Sheet, notwithstanding the deteriorating nature of the Deceased’s condition. This approach to record keeping carries the risk of material information concerning the condition and care of patients not being communicated between medical, nursing and other clinicians; 3) 4) b) Complete records were not provided to the Court in accordance with directions given prior to the inquest. It was understood from the Trust that complete records were unavailable and yet it transpired on the first day of the inquest that further records were available but had not been found and produced previously. I am concerned that the system of record keeping gives rise to a risk that patients’ records which are material to their ongoing care will be lost or otherwise inaccessible. I am concerned that, without records of appropriate quality being made and retained, the opportunity to learn lessons through the process of internal investigations and, should it arise, the Coroner investigation and inquest process will be compromised. c) I am concerned that communications between medical staff, between nursing staff and between medical and nursing staff should be accurate and that it should be ensured that they have been understood. By way of example, in this matter, there was either miscommunication or misunderstanding of the position concerning the taking of an abdominal x‐ray and an apparent miscommunication or misunderstanding of the level of expertise being offered in the interpretation of a chest x‐ray. I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post‐operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol. The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation. 5) Related to 4) above I am concerned that the risk of peritonitis may have been shrouded by the identified risks of sepsis and of aspiration pneumonia and that the risk of peritonitis also needs to be identifiable by those providing care for patients following such surgery. 6) The evidence disclosed that certain essential medication had not been retained in close proximity to the Deceased, where it was required. I am concerned that, in such circumstances, essential medication may be required urgently to protect the life of a patient and that systems should be robust enough to ensure that it is available in the correct location. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you BLACKPOOL TEACHING HOSPITALS NHS FOUNDATION TRUST 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 26TH June 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to the following who may find it useful or of interest: CARE QUALITY COMMISSION NHS ENGLAND I 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 01/05/2019 Signature__ T R Holloway (signed electronically)_______________________ Tim Holloway Assistant Coroner Blackpool & Fylde
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.
NHS Blackpool Teaching Hospitals NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR emai lla 19 June 2019 Private & Confidential Mr T R Holloway Assistant Coroner Blackpool & Fylde PO Box 1066 Corporation Street Blackpool FY1 1GB Dear Mr Holloway Re: Regulation 28 report relating to an inquest into the death of James David Fletcher | write on behalf of the Trust in response to your Regulation 28 report following your inquest into the death of James David Fletcher. The Court reached a narrative conclusion and had six matters of concern which I shall address in turn. 1) There may be a lack of disseminated guidance and protocols for the care of those patients who are unable to communicate verbally — The Trust has an Accessible Information Standard Policy allowing for production of information in different languages and formats, including braille. Our Interpretation and Translation Procedure caters for service users who do not speak English or who are hard of hearing. The Trust has two further relevant guidelines, one for the care of people with learning disabilities and the second for the provision of learning disability adapted dementia screening. The first of these was instituted in May 2016 and is currently being reviewed and revised. Within our Emergency Department Blackpool residents are flagged on the electronic patient record if they are known to have learning disabilities thus alerting medical and nursing staff. These alerts automatically populate the electronic patient tracker for those patients who are admitted from the Emergency Department to our Acute Medical Unit. The Trust is currently working with the Data Controller for Fylde and Wyre CCG so that we may introduce a similar flag for Lancashire residents in our catchment area. Within the Trust we have a lead nurse for learning disability who is available to all staff for advice on the care of patients with learning disabilities and we have a programme for Learning Disability Guides who are link members of staff within the different areas of the Trust. This familiarises them with our current guidelines and sources of further information. 2) Concern regarding record keeping — Whilst the Trust has made progress with electronic access to general practice records and partial provision of electronic records within the Emergency Department we have not as yet implemented an Electronic Document Management System (EDMS). A business case was approved by the Trust Board in January 2018 but because of more pressing cost pressures it has not been possible to progress this to date. A revised business case is in development and due for consideration by Executive Directors by the end of this month. Chairman: Pearse Butler Chief Executive: Kevin McGee (Interim) RESEARCH MATTERS AND SAVES LIVES - TODAY'S RESEARCH IS TOMORROW'S CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care, We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you £32 disability G9 confident EMPLOYER Blackpool Teaching Hospitals NHS Foundation Trust. 3) Accuracy of communication between medical and nursing staff — The Trust recently introduced a revised early warning score NEWS2 which is a national programme for the recognition of patients who require assessment. There has been a training programme overseen by the Interim Director of Quality Improvement and the Deputy Medical Director to ensure that all staff are aware of this. The above two officers jointly chair the Care of the Acutely Ill Patient workstream within the Trust and have oversight of the roll-out of the training programme. In addition the Trust has a SBAR tool to convey important information between clinicians when patients are being transferred from one area to another area when review of a patient is required. 4) A lack of knowledge about risks of peritonitis in patients who have undergone PEG surgery - As identified in the Serious Incident (SI) investigation report signed off by the Chief Executive in December of last year a death after PEG tube insertion is rare and occurs in less than 1% of procedures and peritonitis too is a rare complication. That notwithstanding, staff should be alert to the risk of peritonitis in any patient who has undergone abdominal surgery and | have issued a Red Alert to all staff in the light of this serious incident investigation to remind them of: vigilance in the post-operative period and of the need to be alert to the possibility of peritonitis; and guidelines on the care of PEG tubes. 5) Risk of peritonitis may be shrouded by risk of sepsis and aspirational pneumonia — It is a clinical fact that in patients who are septic it is often difficult to identify the cause of their sepsis. In Mr Fletcher's case his most likely source was initially thought to be pneumonia. | hope that actions arising from the Red Alert mentioned in point 4 above will address this concern. 6) Approximate availability of essential medication — The practice in the Trust is that all patients on admission have their medication reviewed by the admitting doctor and are then seen by a clinical pharmacist and drugs are prescribed for use within the Trust. Yours sincerely Meher. PROFESSOR MARK O’DONNELL MEDICAL DIRECTOR
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