Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0278, written 6 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Aug 2019 |
|---|---|
| Reference | 2019-0278 |
| Deceased | Prabhaker Kapoor |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham 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: 1) CHIEF EXECUTIVE OF UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST 1 CORONER I am Adam Hodson, Assistant Coroner for Birmingham and Solihull 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. 3 INVESTIGATION and INQUEST On 17/05/2019 I commenced an investigation into the death of Prabhaker Nath Kapoor. The investigation concluded at the end of an inquest on 5th August 2019. The conclusion of the inquest was that of a Narrative Verdict, namely, “death due to aspiration of unthickened fluids in hospital.” 4 CIRCUMSTANCES OF THE DEATH On 19/11/18, the deceased had an unwitnessed fall at home and was admitted to the Emergency Department at Birmingham Heartlands Hospital where he was diagnosed with a fractured neck of the right humerus. He was to be admitted to Ward 24 where the fracture was to be treated conservatively using a brace. He developed pneumonia due to aspirating food and was treated with IV antibiotics. He had previously been assessed in March 2017 by speech and language therapists in the community for a pureed diet and thickened fluids due to dysphagia caused by previous stroke, and a Feeding At Risk form was completed upon admission to Ward 24 on 19/11/2019 for this diet to continue. At 04.55 on 21/11/18, he was found by a member of staff attempting to drink from an unthickened jug of water which had been left near his bedside. He aspirated an unknown quantity of the contents which contributed to his aspiration pneumonia. His condition rapidly deteriorated as a result of this, and despite appropriate treatment, he died and his death was verified at 08.10 on 21/11/18.. Following a post mortem, the medical cause of death was determined to be: 1a) ASPIRATION PNEUMONIA 1b) INHALATION OF LIQUID 2) FRAILTY 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. – I heard evidence that a review of safer swallowing training was to be provided to staff on team training days, and that changes would be made to the MOODLE training package by the Speech and Language Manager. The RCA report carried out by Matron indicated that this should have been completed by 15th May 2019, but in oral evidence it was revealed that this had not been done, and an estimated timeframe for completion could not be provided to me. Whilst it was suggested that confirmation could be submitted to HM Coroner upon successful completion of this review, HM Coroner would be functus officio. I therefore suggest that the Trust consider carrying out this review of safer swallowing and update the MOODLE training package as a matter of urgency. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 1st October 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: 1) Next of Kin of the deceased 2) NHS England 3) Clinical Commissioning Group 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 06/08/2019 Signature Adam Hodson Assistant Coroner Birmingham and Solihull
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.
INHS' University Hospitals Birmingham NHS Foundation Trust Trust Headquarters University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital Birmingham Mindelsohn Way Edgbaston Birmingham, B15 2GW. Our Ref:SB.KS.LTRKAPOOR.01.10.19 1 October 2019 For the attention of Adam Hodson Assistant Coroner for Birmingham and Solihull 50 Newton Street Birmingham Sent by way of email: birmingham.coroner@nhs.net Dear Mr Hodson, Inquest touching the death of Prabhaker Nath Kapoor Response to Regulation 28 Report to prevent future deaths | write in response to the Regulation 28 Report made by you following the Inquest into the death of Mr Kapoor, which concluded on 5 August 2019. University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths regarding a review of safer swallowing and update of our Moodle training package. 1. Review of Moodle training Moodle is an internal training e learning platform used to provide training packages to our staff on a range of subjects. A review of the training package had been commenced prior to the death of Mr Kapoor although it had not been completed at the time of the Inquest. A review has now been undertaken, and the content of the training package has been updated by our Speech and Language Therapy team (SLT) to reflect our standard operating procedures relating to ‘dysphagia’ and patients who are ‘nil by mouth’. The training package is currently being developed and will be available for staff by 21 October 2019. The training package will be available to both new and existing staff. The Moodle package is only one way in which we provide training to our staff around safer swallowing and managing patients with dysphagia. It is an adjunct to a training programme provided by the SLT team, who provide the following training on an annual basis, or more frequently if specifically requested: 1) Ward based training for registered and unregistered nursing staff. Chair: Rt Hon Jacqui Smith Chief Executive: Dr David Rosser 2) Specialist training for patients with disease specific swallowing problems (e.g. head and neck cancer, Parkinson’s disease etc.). 3) Stroke swallow screening training for specialist nurses who screen patients who have had a stroke. 4) Junior doctor/Registrar/Consultant training-explaining signs symptoms and ways to manage swallowing problems. 5) Inservice swallow assessment and management training for allied health professionals. 6) Ward based training to implement the International Dysphagia Diet Standardisation. 2. Review of our training provision Following this incident a task and finish group was set up, chaired by our Deputy Chief Nurse, to review safer swallowing practices across the Trust and to review the ongoing work to align our education provision, policy and procedure documents. Review of standard operating procedures A review of our existing standard operating procedures relating to managing patients who are nil by mouth and managing patients who have dysphagia has been undertaken by our SLT team. Following review the documents have been updated and we are satisfied that they provide all our staff with clear guidance, rationale, and clinical expectations when managing and caring for patients who have dysphagia and/or are placed nil by mouth. There has been consultation with a consultant oncologist, consultant geriatrician, consultant ear nose and throat surgeon, palliative care consultant and lead for nursing education. The standard operating procedures have been reviewed by our task and finish group referred to above and will be reviewed and ratified by our Operational Quality Assurance Group on 1 October 2019. Following ratification the documents will be disseminated to all staff via our communications team and will also appear on our intranet. All that having been said we recognise that the evidence base for restriction of water in those on a thickened fluid regime is extremely weak. There is no NICE recommendation in either direction; NICE simply references a Cochrane systematic review of the limited literature. This systematic review identifies no evidence of excess risk associated with access to water in this group of patients. We will continue to review this literature and determine whether our current procedures remain reasonable. In the meantime we are though clear that trust wide adherence to current recommendations must be maintained. Rolling education programme — ‘preventing harm study days’ We have developed ‘preventing harm’ study days which are provided on a monthly basis to both new and existing staff. The days were created to ensure that all our staff have access to specialist led training. The session includes, amongst other training, education and training on the standard operating procedures referred to above. Practice update A practice update on ‘managing patients with swallowing difficulties in hospital’ has been developed and disseminated to all of our staff by our Quality and Clinical Assurance team in order to raise awareness and minimise the potential risk to patients with dysphagia. Chair: Rt Hon Jacqui Smith Chief Executive: Dr David Rosser | would like to assure you that the concerns raised within the Regulation 28 Report have been taken seriously which | hope is demonstrated by the steps we have taken in reviewing our processes, guidelines, training and education. Yours sincerely, ( AA Medical Director Chair: Rt Hon Jacqui Smith Chief Executive: Dr David Rosser
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