Prevention of Future Deaths reports · 2019

James Francis

Regulation 28 report to prevent future deaths, reference 2019-0202, written 19 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Jun 2019
Reference2019-0202
DeceasedJames Francis
CoronerPenelope Schofield
Coroner areaWest Sussex
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1 Jeremy Nixey, Chief Executive, Shaw Heaithcare, 1 Links Court, Links Business
Park, St Mellons, Cardiff CF3 OLT

2 Sir Andrew Dillon, Chief Executive, NICE, 10 Spring Gardens, London SW1A 2BU

1 | CORONER

tam Karen Harrold, Assistant Coroner for the coroner area of West Sussex

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 /Awww legislation gov uk/ukpga/2009/25/schedule/5

http /Awww legislation gov uk/uksi/2013/1629/made

3 | INVESTIGATION and INQUEST

On 25 April 2017, the Sentor Coroner, Penelope Schofield, commenced an investigation
into the death of James William Francis aged 79 years old

The investigation concluded at the end of the inquest on 6 July 2018 | recorded a
narrative conclusion as follows

James William Francis had a history of falls and balance issues arising from previous
brain surgery and the insertion of a VP shunt The unwitnessed fall in his room on 9 April
2017 caused him to slip onto the floor either from his bed or a wheelchair This minor
trauma was likely to have caused a shearing effect from movement of his brain within
the cranium and led to stretching then rupture of one or more of the cortical veins He
was sick three times some 10 hours later and again overnight Medical assistance was
not sought His condition deteriorated the following morning and a call to a GP surgery
was delayed by 4 hours Further sickness and other symptoms were not recognised until
unconsciousness occurred and this led to an ambulance being called and admission to
hospital where a CT scan confirmed a life threatening clot compressing the brain
Surgery was not advised and despite attempts to reverse anticoagulation medication Mr
Francis died on 11th April 2017 after pailiative care Expert medical evidence confirms
that earlier admission to hospital would not have altered the final outcome

The medical cause of death was recorded as

1a) Subdural Haematoma
1b) Brain Injury

Tc) Fall

CIRCUMSTANCES OF THE DEATH

Mr Francis was a 79 year old gentleman (DOB 8 July 1937) who lived at the Deerswood
Lodge Care Home (the Home) in Crawley, West Sussex He was admitted to
Deerswood Lodge from his daughter's home on 1 January 2016 His past medical
history included a left occipital craniotomy and insertion of a VP shunt in 2001 following
hydrocephalus, acoustic neuroma In 2005, and reported TIA in 2013 As a result, the
Home noted he had periods of unsteadiness and balance difficulties resulting in a
history of falls and he was prone to urine infections He was able to walk short
distances with the assistance of a frame although he required a wheelchair for longer
distances He was on anti-coagulation medication (Rivaroxaban)

Mr Francis had a previous fall at the Home on 1 March 2017 when he fell from his bed
and bumped his head on the floor resulting tn a slight bump and graze on the left side of
his head An ambulance was called and he was taken to hospital but returned to the
Home later the same day

He had_another unwitnessed fall on Sunday 9 April 2017 | heard evidence from Jim’s
wife IJ when she visited the home at noon Jim was in the garden in the shade
having a cup of tea He told her that he had slipped off the bed and landed on his
bottom After discussion with the family during the inquest, it was suggested that
because Jim’s Jegs were weak he may very well have tried to lever himself up off the
bed and his feet slipped from under him causing him to Jand on the floor on his bottom
Jim told i that he had hit his head and had told the staff

By contrast, the night support worker confirmed in her statement that the sensor was
activated in Jim’s room at around 07 30 hours She found Jim on the floor and pressed
the emergency button Jim did not wait for help and levered himself back onto the bed
He was asked if he had hit his head and said no When asked how he had fallen to the
floor, Jim told IE that he was trying to sit on his wheelchair and the wheelchair ran
out from behind him He was checked by a Team Leader for injuries but no bruises were
noted and he indicated that he had not struck his head He remained responsive but
was placed on 30 minute observations in line with standard practice in the Home

During the day, Mr Francis spent time in the garden and was visited by his family By
17 30 — 18 00 Mr Francis told a support worker that he had been sick in the bathroom
By 19 00 — 19 30 he told the same care worker that he had been sick in bed and this
happened again between 20 30 — 21 00 requiring a change of bedsheets He was
therefore sick three times between 17 30 and 2100 This was reported to more senior
and experienced staff but no telephone advice was obtained

Night shift staff started around 22 00 and sometime after 22 00 a support worker heard
Mr Francis vomiting so with the Team Leader they got Mr Francis out of bed and moved
him into the lounge to prevent choking A few hours later there was a second episode
of vomiting and some water was noted He was monitored until morning but he stayed
upright in a chair in the lounge No call was made fo a doctor or telephone advice
obtained

By Monday morning Mr Francis condition was deteriorating and his day care worker
could see Jim was very uncomfortable and trying to be sick He went straightaway to
inform the senior nurse at about 08 40 to 08 45 She said to observed Jim until she
could ring for a GP to attend This call was not made until four hours later at 11 40 after
five separate reports from support staff including the fact Jim was slurring his speech
indeed, the day care worker discussed the need for a doctor to attend with Jim’s wife at
11 00 such was the level of his concern The Team Leader says the call was at 10 40
but the manager reports the call was made at 1141 Standard practice was for GP
visits normally to occur in the afternoon

By 11 40 a support worker reported that Mr Francis was sick again and that this time it

was black but he wasn’t sure if blood was present Other members of staff heard Mr
Francis being sick and this was reported to the Team leader plus it was reported that he
was burning up

By 15 20 the shift handover notes recorded that Mr Francis had become unresponsive
so a 999 call was made The ambulance arrived at 15 26 and left with Mr Francis at
15 49 arriving at the East Surrey hospital at 16 05

ACT scan revealed a large right holohemispheric sub dural haematoma extending into
the falx cerebri and tentorium cerebelli causing 1 6cm midline shift and there was
evidence of uncal herniation on the right side Advice was taken from St George's
Neurosurgical team and a registrar advised by telephone at 16 59 as follows

Not an appropriate candidate for acute neurosurgical intervention Best supportive
medical management Liaise with haematology - reverse rivaroxaban/ any coagulopathy
(aiming INR<1 2, platelets >100), hold any blood thinning medications, ensure
electrolytes are kept within normal range Neuro obs If survives acute presentation,
repeat CT head in 2 weeks and rediscuss with us at point

Mr Francis was treated in accordance with this advice but he sadly died on the 11 April
2017

Following his death no Post Mortem examination was carried out in light of the radiology
report and doctor's referral of a death to the Coroner by IEEE from East Surrey
Hospital giving cause of death as -

1a) Subdural haematoma,
1b) Head injury

CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern In
my opinion there ts 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) Effectiveness of shift handover meetings

| heard evidence from several staff members at different grades including two
support workers responsible for Mr Francis’s daily care, a senior support worker and
a team leader that they were unaware of Mr Francis recent fall or the fact that 30
minute observations needed to be carried out In particular, both key support
workers who knew Mr Francis best failed to carry out the 30 minute observations
during the morning and afternoon shifts and on balance of probabilities it was likely
that neither support worker was told either during the handover meeting or by the
senior staff on duty that this was a requirement that day However, it certainly
seems that both support workers observed Mr Francis on a regular basis throughout
the day and took appropriate action to report his condition and any change to senior
staff In another patient, this lack of handing on of vital information to key members
of staff could be crucial

| was shown a shift handover form but this is basic and contains no additional
guidance or method to highlight particular concerns or need for increased
observations

2) Monitoring & management checks

Related to item 1 above, Is the fact there seem to be a failure of appropriate
management records and checks to ensure that if 30 minute observations were

3)

4)

5)

required that these were undertaken at regular intervals

Delay in calling a GP or making a 111 call for advice & information given to GP
when requesting Home visit

| heard evidence that when Mr Francis was sick three times during the late
afternoon and early evening of the day of his fall, no action was taken to seek out of
hours medical advice

In addition, despite a significant deterioration in Mr Francis condition later in the day
of his fall and more significantly the following morning and after five separate
referrals by the day support worker to the team leader, there was a five hour delay
in making a simple telephone call to request a GP visit Further, there does not
appear to have been any thought given to making a call to NHS 111 for advice It
was also unclear exactly what information was given to the GP surgery to stress the
history and deterioration in Mr Francis condition

Sufficiency of information given to paramedics & position of patient on the
floor

| heard evidence that the Ambulance crew received the call to attend Deerswood at
15 22 and arrived at 15 25 They reported that they found Mr Francis on the floor
leaning up against the dining room char and over to his right side They accepted
that they were assertive but felt this was born from a frustration to find a time critical
patient in such a position and staff were unable to answer basic questions about
past medical history, allergies, mobility, communications for current medication It
appeared to the crew that Mr Francis may have slipped out of the chair and his
position may have compromised his breathing They knew the dispatch occurred at
15 15 and they arrived 15 27 so 12 minutes was available to the care home staff to
prepare for their arrival and gather together all the required information Thelr joint
recollection was that they found some paperwork including details of other residents
and amongst those papers they found some details of Mr Francis medical history
and current medication including balance issues, previous brain tumour in 2010 and
that he was prescribed Riveraxaban plus there was a history of falls The crew were
not concerned that Mr Francis was on the floor and felt that the recovery position
would have been far better than the slumped position they found him in
Nevertheless, they accepted that Mr Francis breathing was fine Again, It took some
time to obtain all the details of the fall and sickness details

Finally, when leaving the building to get the stretcher trolley one of the paramedic
crew heard care home staff arguing about the sickness details that had not been
documented This evidence raises considerable concern regarding the adequacy of
documenting key events in a patient's care such as a fall even if the patient
indicates there was no acute trauma particularly when the patient Is elderly and has
a complicated past medical history

In addition, the paramedic suggested that other care homes have a key document
that can be instantly handed over to them to speed up the handover procedure and
ensure that clinical staff have a full history key information This ts often called a
Hospital Passport and uses simple traffic light alerts to highlight key information
There was no evidence of this kind of simple document in this case

Staff training

| heard evidence from a number of staff members that they had received no training
at all or it was some time (up to 3 years) since they had had any basic first aid
training In addition, the paramedics indicated that when the care home staff were
asked what their protocol and understanding was of a head injury with someone
who was prescribed anticoagulant, it seemed the staff could not answer Nor could

they spot the signs and symptoms of head injury even though this is basic first-aid

It would seem the care home staff had not considered placing Mr Francis on the
floor into the recovery position until requested to do so by the 999 operator From
reading the transcript it suggests that when the operator asked the staff to do this,
efforts were made to comply and then ensure Mr Francis head was tilted to keep the
airway clear and his breathing became a little less shallow Conversely, the
ambulance crew were both very clear that their immediate concern on entering the
room was the poor position of Jim in a seated/slumped position that may have
compromised his airway

In addition one of the team leaders confirmed that she knew Mr Francis had a VP
shunt in place but she was not aware of his past medical history or indeed what
shunt did. This raises concerns about basic aspects of patient care and the
adequacy of staff training

6) Adequacy of NICE guidelines

| heard expert evidence from Prof Mark Wilson, consultant neurosurgeon and
prehospital care specialist at Imperial College NHS Trust He confirmed that what
was more likely to have happened was that very minor trauma triggered the
formation of the subdural haematoma His view was that the shearing force of
landing on his bottom and missing the bed or wheelchair cause stretching and
rupture of one of the cortical veins leading to the bleed In other words there was no
direct head injury but instead there was movement of the brain within the cranium

When considering the care and treatment of Mr Francis at Deerswood Lodge from
the time of the fall to the admission to hospital and whether the delay in seeking
medical advice and attention caused or contributed to death, there was a discussion
about relevant NICE guidelines concerning head injuries and falls The suggestion
was that the existing guidelines may not sufficiently address the fact that this type of
fall in the elderly also needs to be considered 1e non-traumatic head injury leading
to a shearing effect on the brain The suggestion was that this type of slow bleed
may take significantly longer to manifest in terms of observable symptoms such as a
change In alertness or persistent vomiting It certainly seems that the care home
staff did not make the connection

As a result, this raises concerns as to whether this type of incident which must be
frequent in the elderly is adequately taken into account in relevant NICE guidelines

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 14 August 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 1s proposed

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons.

1) The family of James Willam Francis,
2) HE Director of Nursing & Safety, Shaw healthcare

| have also sent It to

1) fF Consultant Neurosurgeon at Imperial College NHS Trust

| 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 :

Date: 19 June 2019

Karen Harced,

Karenkriarrolda
Assistant Coroner
West Sussex

Responses

2 responses 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 Nice (PDF)
N [ C National Institute for 10 Spring Gardens

Health and Care Excellence London
SW1A 2BU

7 August 2019 United Kingdom
+44 (0)300 323 0140

Karen Harrold

HM Assistant Coroner for

West Sussex Coroner’s Service
County Record Office

Orchard Street

Chichester

West Sussex PO19 1DD

Our ref. EH105181

Dear Ms Harold,

Thank you for your letter, dated 19 June 2019, regarding the tragic death of James William
Francis

We have considered the circumstances surrounding Mr Francis’ death and the concerns
raised in your report and in particular the concerns that existing NICE guidance on head
Injury may not be appropriate for instances where a person experiences a non-direct head
trauma

We consider that the NICE guideline on the assessment and early management of head
injury (CG176) Is relevant to the circumstances described, since it covers the assessment
and early management of head injuries caused by both direct and indirect traumas This
includes all patients who presented with a suspect or confirmed traumatic head injury with or
without other major trauma

The guideline defines head injury ‘as any trauma to the head other than superficial injuries to
the face’ |n addition, the guideline specifically defines a ‘closed head injury’ as ‘a blow fo the
head or a severe shaking causing tearing, shearing or stretching of the nerves at the base of
the brain, blood clots in or around the brain or oedema (swelling) of the brain. There 1s no
penetration of the skull or brain tissue by an object, the skull may be fractured but this does
not result in a direct connection between the brain and the outside (see Penetrating Brain
Injury)’ This definition can be found tn the glossary within the full guideline document for
CG176

The guideline is currently undergoing a surveillance review exercise to determine whether it
should be updated As a result of your report, the review Is likely to conclude that an update
1s required so that it is clearer that the guideline applies to indirect head injury (for example,
by making the definition more accessible to users) A final surveillance review decision 1s
due to be published in September 2019

Yours sincerely,

Sir Andrew Dillon
Chief Executive

www.nice.org.uk | nice@nice.org.uk
Response from Shaw Healthcare (PDF)
www.shaw.co.uk

Shaw healthcare (Group) Limited | 1 Links Court | Links Business Park | St. Mellons | Cardiff |CF3 OLT
| (029) 2036 4411 (029) 2036 4322 ~ info@shaw.co.uk \’ www.shaw.co.uk

d Off

Shaw healthcare

15 AUG 2019 wellness » happiness » kindness

~~

Your Ref: 01109-2017
14" August 2019

Karen Harrold

Assistant Coroner for West Sussex
Coroner’s Service

County Record Office

Orchard Street

Chichester

West Sussex

PO19 1DD

Dear Madam

Prevention of Future Death Report - Your Ref: 01109-2019 - Deerswood Lodge, West
Sussex

We are responding in receipt of your Regulation 28 Report to Future Deaths Report and
covering letters addressed to Shaw healthcare Ltd namely Jeremy Nixey (Chief Executive)
an (Director of Nursing and Health and Safety) of 20" June 2019. | am
writing to you on behalf of Shaw healthcare.

Firstly | would like to record again our condolences and on-going thoughts to the later Mr
Francis’s family and to confirm that both locally at Deerswood Lodge residential care home
and within the Shaw healthcare Group we have learned significantly, completed a number
of revisions and actions both locally and nationally which within this letter | will clarify
details on actions we have taken and salient timescales.

Within your report you raised six specific matters of concern where actions were required.

1) Effectiveness of shift handover meetings

2) Monitoring & management checks

3) Delay in calling a GP or making a 111 call for advice & information given to GP when
requesting Home visit

4) Sufficiency of information given to paramedics & position of patient on the floor

5) Staff training :

6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a
response is required from the Chief Executive of NICE. We will of course fully work to
any revised set of NICE guidelines.

- EAC Housing
- UK Over 50's Housing Awards
©) shawhealthcare - National Caring Times Care Awards

@shawhealthcare

t Act 1985, R Yo 5391089. & 1& Wa

Shaw healthcare

Our responses and actions to areas 1) to 5) are as follows: -
1. Effectiveness of shift handover meetings

Prior to your inquest we had already recognised a need to improve our handover
arrangements at Deerswood and in March 2018 we had set up the attached “Shift Handover
Form”.

In addition we expect the following process to be completed at every handover at every
service: -

a) Identify the personnel who need to attend the handover, ensuring cover is
available.

b) Person in Charge on outgoing shift must handover to Person in Charge on incoming
shift.

c) Conduct handover in a detailed concise manner using the corporate Handover
Form.

d) Record start time and end time of handover.

e) Provide verbal and written information regarding:

a. All Service Users (Names)
b. A brief summary against Service User’s names
c. Complete the tick boxes where relevant

f) All written and verbal communication to maintain Service User confidentiality and
comply with good practice and data protection legislation and guidance.

g) Confirm those who are receiving the handover have understood the information
provided and clarify any resulting queries or concerns.

h) The Handover form must be signed by the Person in Charge on the out going shift
and the Person in Charge on the incoming shift.

i) Incoming Person in Charge must allocate staff to locations, Service User, key-
worker groups.

j) Incoming Person in Charge to allocate keys, pagers, DECT phones etc where
appropriate.

k) Within 30 minutes of taking handover the incoming Person in Charge must check all
service users in the building i.e. walkabout and headcount - and must undertake a
visual check on those identified as deteriorating or poorly. The incoming Person in
Charge must sign the Handover Sheet to confirm. To include a security check of the
building.

\) The completed handover sheets are to be filed in the designated folder in the Unit
Office and remain accessible for future reference.

This action has been completed and will be reviewed on an on-going basis.
2. Monitoring & management checks

In November 2017 we had implemented a completely revised “Prevention and Management
of Falls” Policy which | have also attached for verification.

The objectives of this policy are to ensure Service Users who are at risk of falls are
identified on admission to the service; Multi-factorial falls risk assessments identifies
person centred risk factors for falls; Effective management, treatment and safe care of the
Service User is delivered immediately after a fall; the risks of further falls is minimised
through the implementation of effective, person centred interventions. And we seek that
all staff should read the policy in conjunction with the Head Injuries policy and the Bed
Rails Policy.

2/4

Shaw healthcare

Each Service User has a Falls Risk Assessment (and also attached) which we require the
newly admitted person to be assessed and completed within 4 hours of their admission to
any Shaw care home. Re-assessments should be completed following any fall and/or as
appropriate.

Each service has an IPRO Falls Risk Tracker in place where the home manager will be
completing on-going assessments, analysis and review within their service.

This action has been completed and will be reviewed on an on-going basis.

3. Delay in calling a GP or making a 111 call for advice & information given to GP when
requesting Home visit

We have all learned from the regrettable circumstances surrounding the deterioration in
Mr Francis’s condition during the latter part of the day of his fall.

All care staff now receive training on “Recognising a Deteriorating Service User” and in
addition they also all receive first aid training.

| also refer to the attached “Request for attendance of GP” policy which states that if a
Service User develops a health problem or if the Service User requests to see their GP, the
senior person on duty will assess the situation and contact the surgery, before the
medication round commences. In assessing the urgency of the situation, the GP Surgery
can be approached for advice or otherwise to liaise with the District Nursing service as
appropriate it goes on to set very clear expectations in referring to the NHS 111 service
also and the importance of clear communications.

We expect every service manager to monitor this within their service and our auditing
systems at local level check the application of this.

This action has been completed and will be reviewed on an on-going basis.
4. Sufficiency of information given to paramedics & position of patient on the floor

Care planning, daily records from assessments and evaluations continue to be improved at
Deerswood. For our 12 care homes in West Sussex we have recruited two Quality
Improvement Managers where their primary function is to ensure improvements in service
provision including the completion of care records - along with mentoring, supervising and
role-modelling to care and nursing staff.

| also note that paramedic referred to the Hospital Passport. We have adapted the Hospital
Passport - Transport Traffic Light System within all our West Sussex care homes initially
and through the wider company. This is to provide the paramedic and hospital staff the
most helpful information that isn't only about illness and health. This accompanies the
Service User to inform and support. It is implemented within our Care Plan systems.

In addition the increase in training including the “Recognising a Deteriorating Service User”
and first aid training reported in 3 above and in our response to area 5 covers the
necessary need to improve communication not just to GPs and paramedics but to all
relevant professionals.

This action has been completed and will be reviewed on an on-going basis.

3/4

at

~ Shawhealthcare
5. Staff training

We have covered the very necessary responses required by you throughout this report. We
have significantly increased training and awareness, every service has a completed
Training Metrics where we expect 90% of all staff at any one time to have completed all
mandatory training.

All Shaw healthcare employees caring/working with any Service Users who is at risk of
falling will be up to date in their Manual Handling training and their competency assessed
by a senior staff member who has been accredited by the Company. They must attend a
first aid training course and ensure that this certification remains current throughout their
employment.

And we require all First Aiders to respond to any first aid situations by following the
correct first aid procedure. There is at least one First Aider on duty at every shift.

This action has been completed and will be reviewed on an on-going basis.

In conclusion, we respectfully regret the events surrounding Mr Francis’s fall at
Deerswood, we all - that is the management and staff at Deerswood Lodge, the wider
regional management and nationally of Shaw healthcare have learned from this incident.
We have taken some tough and very necessary actions and we have changed our practice,
training and policies.

If you require any further information or detailing please do not hesitate to contact me.

Yours sincerely

irector of Compliance & Governance

Cc. Jeremy Nixey, Chief Executive, Shaw healthcare Ltd
a "ecto of Nursing and Health and Safety, Shaw healthcare Ltd

4/4

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