Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0326, written 30 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Sep 2019 |
|---|---|
| Reference | 2019-0326 |
| Deceased | Charles Williamson |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health, Mayor of Greater Manchester, GM Health and Social Care Partnership CORONER | am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 6 June 2019 | commenced an investigation into the death of Charles Williamson. The investigation concluded on the 25" September 2019 and the conclusion was one of Accidental death. The medical cause of death was 1a) Urinary tract infection on a background of catheterisation;1b) Traumatic brain injury; and 2) Hospital acquired pneumonia CIRCUMSTANCES OF THE DEATH Charles Williamson fell in Portugal suffering a significant traumatic brain injury. He was repatriated to England and admitted to Wythenshawe Hospital. A scan identified an enlargement of the chronic subdural haematoma. A drainage operation was performed at Saiford Royal Hospital. He was moved back to Wythenshawe subsequently. A scan on 16! February 2019 showed a recurrence of the chronic subdural haematoma. A further successful drainage procedure was undertaken at Salford Royal Hospital. He was subsequently again returned to Wythenshawe Hospital. On 18"" March 2019 further tests concluded with a MR scan showing a likely infection in the brain. He was transferred to Salford Royal Hospital for a craniotomy. He was on antibiotics for 6 weeks initially at Salford Royal Hospital and then at Wythenshawe. He was transferred to the neuro-rehabilitation unit at Trafford on 17" April 2019 he continued to deteriorate with confusion and loss of mobility. He was catheterised as a consequence. He showed signs of an infection which was a urinary tract infection and a pneumonia. He was treated with antibiotics. He continued to decline and died at Tameside General Hospital on 5" June 2019. 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. The MATTERS OF CONCERN are as follows. — The inquest heard that following neurological incidents such as those sustained by Mr Williamson it will often be the case that a key to returning to baseline or closer to baseline is effective and early neuro-rehabilitation. The inquest was told that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester was in some cases preventing early effective neuro-rehabilitation and increasing the risk of complications which could lead to death. 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 25"" November 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following iP] Interested Persons namely 0 behalf of the family, 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. Alison Mutch OBE HM Senior Coroner 30.09.2019
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.
GMCA GREATER MANCHESTER COMBINED AUTHORITY ,,,,:;j in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN T: 07825 675 823 E: Your Ref: 13104/CH 21 November2019 Ms A Mutch OBE HM Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK13AG Dear Ms Mutch Re: Regulation 28 Report - Charles WILLIAMSON I write in response to your letter of 03 October 2019. Attached to this letter is a report that I hope you will agree addresses the concerns you outlined in respect of the above case. Please do not hesitate to contact me if I can be of further help. Yours sincerely Dr Richard Preece Executive Lead for Quality and Medical Director Greater Manct]esle1 Heam1 and Social Care Partnership 1s made up of all the NHS orgarnsat1ons and counc,ls 1n the city region •·) We're overseeing devolution and taking charge of the £6bn health and sacral care budget. -. , ·-· Greater Manchester Neuro-rehabilitation Services Prepared for a response to a Regulation 28 Report from HM Coroner, Manchester South October 2019 Since 2016, Greater Manchester neuro-rehabilitation services have been considered a priority for service transformation by providers, commissioners and the Greater Manchester Health & Social Care Partnership. The design of the model of care for the future neuro-rehabilitation services was clinically- led and developed in collaboration with commissioners and service users. Greater Manchester neuro- rehabilitation services are at an exciting time, as the transformation of inpatient services has commenced and to date, seven out of the 12 areas of Greater Manchester have received additional investment into community neuro-rehabilitation services. Please see below for a summary of the reasons for the service changes, the new model of care and the benefits that these services changes will bring. These changes will help to minimise any risks to patients in Greater Manchester who would benefit from Neuro-rehabilitation. Particularly relevant to this Coroner's report, the planned changes will ensure robust referral pathways between provider sites, seamless transfer, mechanisms to track patients across sites within a single Greater Manchester service and patients referred and admitted to the most appropriate level of care to meet their needs. Improved continuity of care will be via a single GM-wide in-patient team and the consistent application of high quality rehabilitation care. Current Arrangements Regarding Neuro-Rehabilitation Services in Greater Manchester Neuro-rehabilitation services in Greater Manchester are commissioned by NHS England and Clinical Commissioning Groups as follows: Service 30 Level 1 Hyper-Acute and Acute Beds at Salford Royal Hospital serving the whole of the Greater Manchester conurbation 87 Post-Acute Beds provided by three different providers and distributed as follows: - - - 18 beds at the Floyd Unit serving Bury, Oldham and Rochdale areas 19 beds at the Devonshire Centre serving Stockport, Tameside & Glossop, East Cheshire & North Derbyshire SO beds (40 open) at Trafford General Hospital serving North, Central and South Manchester, Trafford, Salford, Bolton and Wigan Community Neuro-Rehabilitation Services Slow-Stream Neuro-Rehabilitation Beds Commissioner NHS England Greater Manchester Clinical Commissioning Groups Greater Manchester Clinical Each Commissioning Group commissions a local service covering their local area, with the exception of South Manchester Each Commissioning Group stream neuro-rehabilitation beds independent sector on an ad hoc basis Clinical comm1ss1ons slow- the Manchester Greater from Case for Change In 2017, the case for changing the neuro-rehabilitation services highlighted several reasons to change inpatient neuro-rehabilitation services. This included: • • • • • sub optimal patient flow into and out of neuro-rehabilitation services, Improvements needed in the care of patients with a tracheostomy (due to neurological deficits) or prolonged disorder of consciousness, ad hoc access to slow-stream neuro-rehabilitation, usually from independent sector providers and often outside of Greater Manchester, variation in access and service provision, including waiting times to access the services, practices within services, admission and discharge planning, staffing levels and outcomes, variation in commissioner investment and provider tariffs, with shortfall and variation in staffing levels, • multiple commissioners of the GM services, and • increased demand. These drivers for change informed the design of the new neuro-rehabilitation model of care for Greater Manchester. New Model of Care for Greater Manchest er Neuro-Rehabilitation Services The new model of care design, agreed ln 2018, describes Greater Manchester neuro-rehabilitation services as follows: • • • • • A single provider of the bed based (inpatient) GM Neuro-Rehabilitatlon service, As now, 30 hyper-acute and acute Neuro-Rehabllitation beds on the Salford Royal Foundation Trust site, In addition, up to 10 beds for the management of patients with tracheostomy and/or prolonged disorder of consciousness (as an alternative to ad hoc commissioned beds in the independent sector), 60 beds for post-acute Neuro-Rehabilitation (27 fewer beds than the current model), 20 new NHS beds for patients requiring slow stream neuro-rehabilitation (as an alternative to ad hoc commissioned beds in the independent sector), • Community neuro-rehabilitation services in every locality area providing patients with a consistent service offer, regardless of postcode, and • Consistent oversight, commissioning and review of all patients in ad hoc placements in the independent sector. The Greater Manchester Joint Commissioning Board agreed the business case for the new model of care in June 2019. The business case also included an agreement for the bed day tariff to be increased and standardised across the inpatient services. Benefits of the New Greater Manchester Neuro-Rehabilitation Services The anticipated benefits of the new Greater Manchester neuro-rehabilitation services are: • • • Earlier access to neuro-rehabilitation, requirements via the single point of access, Improved staffing levels enabling greater intensity of rehabilitation, Access to services/professionals not currently accessible to all patients, including consistent assessment of rehabilitat ion • • • • • • • Increased NHS neuro-rehabilitation beds (as an alternative to independent sector), Increased opportunities for rehabilitation at home/in the community, Increased consistency of care, Improved patient outcomes and experience, Reduced lengths of stay in hospital beds, Improved patient flow and management of beds supporting patients being treated in the right place at the right time, and Improved review of patients within independent sector beds. Implementation of the New Greater Manchester Neuro-Rehabilitation Service Inpatient Neuro-rehabilitation Services: Salford Royal NHS Foundation Trust (SRFT) has been selected as the single provider for the inpatient (bed-based) part of the neuro-rehabilitation service model. SRFT commenced work in July 2019 to plan for the transfer of the current NHS inpatient services into the management of Salford Royal. Transfer of the services is expected to take place during January-March 2020 20 slow-stream neuro-rehabilitation beds will be established during May-December 2020 Estate options for the 10 post-acute tracheostomy/prolonged disorder of consciousness beds are currently being worked through and as such a definitive timescale for establishing these 10 beds has not yet been agreed Community Neuro-rehabilitation Services: Each Greater Manchester Clinical Commissioning Group has agreed to commission a community neuro-rehabilitation service as per the agreed Greater Manchester community neuro-rehabilitation service specification. Whilst the progress for achieving consistency of commissioning & provision of community neuro-rehabilitation services varies across the region, there is a commitment by every CCG to have commissioned a service as per the agreed specification by April 2020. Ongoing work by Neuro-Rehabilitation Services Throughout the process of developing a case for change, a new model of care and business case for a new neuro-rehabilitation service, community and inpatient services have undertaken significant work to improve their services. For example: Improved discharge planning practices to improve patient's experience of the discharge process, reduce length of stay and improve patient flow Establishment of a complex discharge service to improve patient's experience ofthe discharge process, reduce length of stay and improve patient flow Community service in-reach into inpatient neuro-rehabilitation services to support people being discharged into the community Development of community and inpatient service standards Peer review of inpatient services Development of a GM-wide training & education programme and resources Development of a GM neuro-rehabilitation patient & carer network to ensure patient & carer involvement in service improvement and development work Improved consistency of processes and documentation .. Timeline of Key Decisions for Neuro-Rehabilitation Services December 2015: September 2016: August 2017: April 2018: October 2018: November 2018: March 2019: June 2019: July 2019: GM CCG Directors of Commissioning consider the strategic outline case for changing neuro-rehabilitation services and agree for the work to develop a case & model of care to proceed Inpatient neuro-rehabilitation services were identified as one of the priorities for transformation by the GM Health & Social Care Partnership St rategic Board Improving specialist Care Programme (ISCP) board and executive (set up to deliver the strategy outlined in the Greater Manchester (GM) Health and Social Care Partnership strategic plan 'Taking Charge') agree the case for change for neuro-rehabilitation services The neuro-rehab model of care was agreed by the ISCP board and executive The GM Health & Care Joint Commissioning Board (JCB) approve t he model of care The GM Joint Overview and Scrutiny Committee conclude that formal public consultation regarding the model of care was not required as involvement and engagement activities had been proportionate to the number of patients affected by the proposed changes The JCB approve the single provider as t he GM Neurosciences Centre (Salford Royal NHS Foundation Trust) The JCB approve the business case for the GM neuro-rehabilitation model of care Salford Roya l NHS Foundation Trust commence implement ation planning for the inpatient neuro-rehabilitation service transformation
• Department of Health & Social Care Your Ref: 13104/CH Our Ref: PFD-1192584 Ms Alison Mutch QBE HM Senior Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG r, . (~ l\ l , N\vJ-->. - V\./ \ vu From Nadine Dorries MP Parliamentary Under Secretary of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H0EU 020 7210 4850 ;) 5 March 2020 Thank you for your correspondence to Matt Hancock dated 30 September 2019 about the death of Charles Williamson. I am replying as Minister with responsibility for patient safety and I offer my apologies for the delay in responding. Firstly, I would like to say how sorry I was to read the circumstances of Mr Williamson's death. Please offer my condolences to his wife and loved ones. From the information in your report, it appears that access to neuro-rehabilitation services was not a factor in Mr Williamson's death. However, I agree with you that access to early and effective neuro-rehabilitation services is key to recovery for patients that have sustained a head injury. The provision of neuro-rehabilitation services in Greater Manchester is a matter for local NHS commissioners. The Greater Manchester Health and Social Care Partnership (GMHSCP} was formed in 2016, bringing together local authorities, NHS commissioners, NHS providers and the Mayoral Combined Authority to oversee the health and social care devolution programme in Greater Manchester. The GMHSCP has control of a £6 billion health and social care budget that is used to provide integrated care. I am aware that the GMHSCP has advised in its response to your report that the NHS in Greater Manchester is working to implement a new model of care for neuro-rehabilitation services to ensure that patients are referred to the right level of care, at the right time and with consistent quality standards. This followed engagement activities with patients and others on the new model of care. I am advised that the expected benefits of moving to a single service across Greater Manchester include improved referral pathways, better continuity of care and increased opportunities for rehabilitation at home and in the community. In addition to changes to the configuration of neuro-rehabilitation services, the NHS in Greater Manchester is undertaking work to improve the quality of inpatient and community neuro-rehabilitation services. This includes the development of service standards and improved discharge planning and processes. I am advised that by April 2020, each clinical commissioning group (CCG) in Greater Manchester has committed to commission a neuro-rehabilitation service in line with the newly developed service specification. I hope this information is helpful and provides assurance about the future provision of neuro-rehabilitation services in Greater Manchester. Thank you for bringing your concerns to my attention. NADINE DORRIES
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.