Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0279, written 2 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 | 2 Aug 2019 |
|---|---|
| Reference | 2019-0279 |
| Deceased | Carol Jennings |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT !S BEING SENT TO: The Chief Executive Queen Elizabeth Hospital Gayton Road King’s Lynn Norfolk PE30 4ET 1 CORONER lam Jacqueline LAKE, Senior Coroner for the area of Norfolk 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 06/02/2019, | commenced an investigation into the death of Carol Anne JENNINGS aged 79. The investigation concluded at the end of the inquest on 01/08/2019. The conclusion of the inquest was: Natural causes. The medical cause of death: 1a Septicaemia 1b Infected Leg Ulcers, Hospital Acquired Pneumonia ic ll Chronic Kidney Disease 4 CIRCUMSTANCES OF THE DEATH Mrs Jennings had a number of comorbidities including lymphedema, bilateral venous leg ulcers and chronic liver disease. She had several admissions to hospital due to infections. Mrs Jennings was admitted to Queen Elizabeth Hospital on 10 January 2019 due to high potassium levels. Mrs Jennings was referred to the Tissue Viability Nurse on 12 January 2019 but was not seen. She was started on antibiotics on 15 January 2019 and considered for discharge on 18 January 2019 but then remained in hospital. On 21 January 2019, Mrs Jennings legs were examined and considered to have infected leg ulcers and !V antibiotics started. She was reviewed on 23 January 2019 and no infection of the ulcers was noted. Mrs Jennings’ condition deteriorated, and she was started on end of life care on 25 January 2019 and she died on 31 January 2019. 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 taken. in the circumstances, it is my statutory duty to report to you. BY 4 The matters of concern are as follows: 1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented. 2. The evidence revealed a lack of and/or inadequate record keeping. Mrs Jennings was admitted to hospital on 10 January 2019 and there is no detailed record describing the wound until 21 January 2019 and no measurement of the wound until 23 January 2019. There are no photographs of the wound. A wound assessment form was not completed. At the resumed inquest no steps had been taken to ensure full and proper record keeping. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has 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 27 September 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: Mr Paul Jennings and Mr Christopher Jennings - sons | | have also sent it to: Department of Health cac HSIB Healthwatch Norfolk who may find it useful or of interest. | 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 Dated: 02/08/2019 Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service Carrow House 301 King Street Norwich NR12TN
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| The Queen Elizabeth Hospital King’s Lynn 27 SEP 2019 NHS Foundation Trust The Queen Elizabeth Hospital Gayton Road Kings Lynn Norfolk PE30 4ET www.gehkl.nhs.uk 25 September 2019 Mrs J Lake HM Coroner for Norfolk Carrow House 301 King Street Norwich NR1 2TN Dear Mrs Lake Inquest - Carol Anne Jennings (deceased) - Regulation 28 Report In response to your Report under Regulation 28 of the Coroner's Rules | wish to set out our reply below. You raised two concerns, the first being about patient referrals to our Tissue Viability Nurse (TVN) service and the second relating to the completion of nursing records. 1. Referrals to the TVN service A new electronic referral system will be in place during the first week of next month. As compared with the previous system involving telephone referrals and the practice of answering machine use, which is being discarded, there is now a new e-form which must be used in all cases. The e-form must only be emailed to the TVN nurse as indicated and the referral form’s design means that correct and accurate information about the patient must be included so that the referral and response is efficiently conducted by the TVN. A copy of that form is attached for your information. 2. Nursing documentation We have a number of initiatives in relation to nursing documentation as a result of our recent CQC inspections and these changes are being overseen by our Conditions Notices and Oversight Group. Under the heading of nursing documentation the key improvements put in place are: e The Department responsible for the area in which Mrs Jennings was treated has a new divisional leadership team (Division 2) which has been in place since August. 25 September 2019 The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust A weekly Documentation Task and Finish Group was set up and commenced business on 21* August 2019. The Chief Nurse is the executive lead and has oversight of this meeting and it is attended by the Matrons and Ward Managers. The weekly documentation and risk assessment audits are to be maintained and for Division 2 overall the most recent recorded compliance rate is 90.5%. The Stop the Clock and SBAR (Situation, Background, Assessment, Recommendation) campaign continues within Acute Medicine. “Stop the Clock” is an initiative started by our Assessment Zone nursing staff which advocates stopping the time to gain situational awareness of risk pertaining to a task. It allows staff to check and challenge potentially unsafe practice when transferring and receiving patients before it happens. This is enhanced by using the SBAR tool as a prompt to ensure that appropriate information is relayed. | understand that Mrs Jennings was moved twice within the Acute Medicine Department and that loss of continuity may have been a factor in the problems with the associated record keeping. Training for core and clinical induction now covers record keeping alongside the NEWS2 early warning system. The Rapid Assessment Team has introduced a checklist for aiding communication among the acute medical teams and this will be in use in October. Our acute medical wards have started a roll-out of new standardised blue folders which contain the most active parts of the nursing medical records. This encompasses our most acute clinical areas, including the Acute Medical Unit and the Assessment Zone. Wound assessment documentation also falls within the scope of this change. In addition, bespoke training on the ward is given to new staff who may be unfamiliar with the blue folder documentation. The intention is that standardisation means that regardless of the patient’s movement through the Acute Medicine Department, the documentation will be continuous and consistent. Yours sincerely Cal ary Caroline Shaw Chief Executive Page 2 of 2
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