Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0360, written 8 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Oct 2019 |
|---|---|
| Reference | 2019-0360 |
| Deceased | Mary Chapman |
| Coroner | Claire Welch |
| Coroner area | Cheshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Steve Gray, Chief Executive, Nuffield Health 2. , Quality Care Partner, Nuffield Health 1 CORONER I am Claire Welch, Area Coroner for the coroner area of Cheshire. 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 9 March 2018 I commenced an investigation into the death of Mary Jane Chapman, 55 years of age. The investigation concluded at the end of an inquest on 7 October 2019, after hearing evidence on 25-27 September 2019. The medical cause of death was 1a Large myocardial infarction 1b left descending coronary artery thrombosis 1c catastrophic antiphospholipid syndrome and my conclusion at the end of the inquest was natural causes. 4 CIRCUMSTANCES OF THE DEATH Mary Chapman underwent an elective right total knee replacement at the Nuffield Hospital in Chester on 13 February 2018. She was discharged on 16 February 2018, at which point her platelet count was 74 meaning that she required a repeat blood test a week later to check her platelet count. Due to a combination of reasons relating to the management of the discharge process at the Nuffield Hospital, that blood test was not arranged: the discharging doctor did not arrange the follow up test to be done at the Nuffield Hospital; the discharging doctor verbally told the discharge nurse that the GP needed to do a follow up blood test in a week but did not document anything about this or give any instruction as to how this was to be communicated to the GP; the discharging doctor did not write directly to the GP to notify him of the need or reason for a follow up blood test in a week; the discharging doctor did not communicate the low platelet count to the consultant to enable him to write to the GP about the need for a follow up blood test in a week; the discharging nurse did not include the need for a follow up blood test in the discharge summary sent to the GP; and neither the discharging doctor nor the discharging nurse adequately explained the need for a follow up blood test to Ms Chapman. Ms Chapman was admitted to the Countess of Chester Hospital on 28 February because of a dangerously low platelet count of 7. Despite intensive medical treatment for a range of possible causes of it, she died on 4 March 2018. Her death was the result of a large myocardial infarction brought on by a left descending coronary artery thrombus, the underlying cause of which was the acute onset of Catastrophic Antiphospholipid Syndrome, a naturally-occurring auto-immune condition, the trigger for 1 which could not be ascertained. Although I concluded that the failure to ensure that a follow-up blood test was arranged did not cause or contribute to the death, it is my opinion that ongoing uncertainties in the discharge process means there is a risk that future deaths will occur unless action is taken. 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. The MATTERS OF CONCERN are as follows. – 1) Although a Nuffield-wide ‘discharge policy’ has been created, the document is lengthy, unwieldy and generic. It does not clearly define who is responsible for doing what, or when, as part of the discharge process and there is no clear local or Nuffield-wide guidance document or policy that achieves this; 3) for critical post-discharge 2) There is no clear local or Nuffield-wide guidance document or policy on how the investigations should be arranged or need communicated, or by whom or when; In respect of (1) and (2) above there was no evidence at the inquest that clinical and nursing staff are now aware of their individual roles and responsibilities in the discharge process, other than as part of a new induction process, which self- evidently only captures new staff. Equally, despite 18 months having elapsed since the death, there was no evidence at the inquest to demonstrate that such changes as have been implemented have improved the quality, accuracy and robustness of discharge communications; 4) The inquest heard evidence that, since the death, the need for doctors to fully document their intended plan for follow-up investigations in the notes has been reinforced. Despite the importance of this as part of the discharge process, there was no evidence to demonstrate that this has resulted in improved record keeping or that the same has resulted in more robust and accurate discharge communications; 5) The inquest heard that it is accepted that there is a need for a multi-disciplinary team approach to risk assessing patterns with low platelet counts, but there was no document or policy addressing this new approach. There was no evidence of how such an approach should work in practice and there was no evidence to demonstrate that the new approach has improved the risk management of such patients; 6) The fact that Nuffield is a private hospital means that the doctors working there are likely to come from a variety of different hospitals and will be used to a variety of different working practices. Whilst the decision about what post- discharge investigations are required is clearly a matter of clinical judgment, the responsibility for ensuring that clear and unambiguous procedures exist to implement those clinical decisions lies with the Nuffield. 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, 2 namely by 3 December 2019. I, the Area 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, the CQC, Chapman’s partner), the legal representative of Chapman’s siblings) and counsel for the legal representative of (Ms (Ms . 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 8 October 2019 3
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.
Nuffield Health response to the Regulation 28 report to prevent future deaths issued by HM Area Coroner Claire Welch for Cheshire on 8 October 2019 following investigation and inquest into the death of Mary Jane Chapman. Nuffield Health: Introduction Nuffield Health is the UK’s largest healthcare charity and as an organisation with no shareholders, we invest all our income back into our vision to build a healthier nation. We do this through services in our family of 31 hospitals, 112 fitness and wellbeing clubs, healthcare clinics and emotional wellbeing services. We operate as a responsible charity and are proud of our commitment to our flagship programmes to widen access to our services. This includes improving the lives of hundreds of children with cystic fibrosis through free exercise classes; pioneering the world’s largest research project into how exercise can help men recovering from prostate cancer and working in partnership with schools to provide thousands of pupils with free timetabled programmes to improve their health and wellbeing. Within the DNA of our charity is our values framework. We put our patients, customers and colleagues at the heart of everything we do because we CARE: this reflects our ethos: Connected, Aspirational, Responsive and Ethical. Background to the Regulation 28 Report HM Coroner Claire Welch, Area Coroner for Cheshire, held an inquest into the death of Mary Jane Chapman on 25-27 September 2019. *Throughout this report, we shall refer to the patient as Mary, consistent with the terms of reference agreed with the family at the inquest. Mary underwent an elective right total knee replacement at the Nuffield Health Hospital Chester (“the Hospital”) on 13 February 2018 and was discharged home 3 days later. During her pathway of care, she had a low platelet count and at the time of discharge, had a platelet count of 74. Due to a combination of reasons relating to the discharge process, an intended blood test by the GP approximately one week post-discharge was not undertaken. Mary was admitted to the Countess of Chester NHS Hospital on 28 February 2018 and despite intensive medical treatment, she sadly died on 4 March 2018. The cause of death was a large myocardial infarction due to a left descending coronary thrombus, the underlying cause of which we now understand to be Catastrophic Antiphospholipid Syndrome (CAPS). Antiphospholipid Syndrome (APS) is a naturally occurring autoimmune condition; the trigger for this developing into CAPS could not be ascertained. Coroner’s concerns: Although HM Coroner concluded that the apparent failure to ensure the follow-up blood test was undertaken in a timely manner did not cause or contribute to Mary’s death, it was her opinion that Nuffield Health, Epsom Gateway, Ashley Avenue, Epsom, Surrey, KT18 5AL A registered Charity Number: 205533 (England & Wales), a Charity Registered in Scotland Number: SC041793 and a Company Limited by Guarantee Registered in England Number: 576970, VAT No GB 564 29 1137 ongoing uncertainties in the Hospital’s discharge process presented an ongoing risk to patient safety, in the absence of further action being taken. It was for this reason that a (Regulation 28) report to prevent future deaths was issued to Nuffield Health with a requirement to respond by 3 December 2019. Matters of concern: 1) Although the Nuffield Health Discharge Policy was revised in 2018 as a direct consequence of learning following the internal investigation into this event, the document was considered by HM Coroner to be lengthy, unwieldy and generic. HM Coroner was particularly concerned that the policy did not give sufficient clarity to who is responsible for doing what, or when, as part of the discharge process. 2) A lack of policy or guidance for arranging critical post-discharge investigations. 3) In respect of 1) and 2) above there was no evidence at the inquest to give assurance that clinical and nursing staff are now aware of their roles and responsibilities in the discharge process. Equally, there was no evidence that such changes (as have been implemented) have improved the quality, accuracy and robustness of discharge communications. 4) Despite reinforcing the need for doctors to document fully their intended plan for follow up investigations in the medical records, there was no evidence to demonstrate that this resulted in improved record keeping or more robust and accurate discharge communications. 5) There was no document or policy to guide the multi-disciplinary risk assessment of patients with low platelet counts. There was no evidence of how such an approach should work in practice nor evidence to demonstrate the approach has improved the risk assessment of such patients. 6) As consultants working at Nuffield Health come from a variety of hospitals with different practices, and acknowledging clinical judgment will inform individual discharge plans, the responsibility for ensuring clear and unambiguous procedures sits with Nuffield Health. Nuffield Health’s response to HM Coroner’s Regulation 28 findings Immediate Actions: Upon receipt of the Regulation 28 report to prevent future deaths, Nuffield Health’s CEO, Steve Gray, to lead the response keeping him, the tasked the Clinical Director and Chief Nurse, Executive Board and Governors routinely updated on progress at their monthly Board meetings. sent a letter of acknowledgement to HM Coroner the day following receipt of the report. , Hospital Director at Chester Hospital Immediately following a period of annual leave sent a letter of acknowledgement to Mary’s partner on 21 October 2019. In this, he gave assurance as to how seriously the Regulation 28 report is being taken and explained that a copy of our response will be shared with her once complete. will make arrangements to meet with her to discuss the actions and changes, if she feels this would be helpful. also advised that Registered Charity: 205533 (England & Wales) SC041793 (Scotland) Company Limited by Guarantee Registered in England 576970 Quality Care Partner (QCP) Quality Improvement and therefore part of the Clinical Directorate senior leadership team co-ordinated and implemented the action plan involving the Medical Director, clinical subject matter experts and senior leaders at hospital level as required. A copy of the action plan as of 30 November 2019 is attached; Appendix A. Subsequent Actions: For clarity, the number assigned to each of the actions listed below correlates with the number of the concerns listed above: 1) The revised Nuffield Health Policy (Appendix B) is rewritten paying particular attention to clarity of role and responsibilities associated with different professionals within the multidisciplinary team, with regard to the patient discharge process. The process itself has greater clarity and considers all scenarios that may present for patients using Nuffield Health services. 2) The revised Nuffield Health discharge policy includes the process for arranging critical post-discharge investigations. 3) The role & responsibilities of all professionals working within the multidisciplinary clinical team are clear within the revised policy and an audit process, which is currently being tested, will be used across all hospitals to monitor the efficacy of the process and the patient experience. This audit is on our electronic Quality Management System (QMS). The list of questions that make up the audit are attached at Appendix C but please note that this does not show the on-line format which is user-friendly with clear headings. Section 7 onwards of the audit is of particular relevance 4) Every medical practitioner working within Nuffield Hospitals received a communication: (i) Consultants Within 4 working days of receiving the Regulation 28 report to prevent future deaths the Medical Director for Nuffield Hospitals issued a communication for all consultants with practising privileges reiterating their responsibilities in relation to contemporaneous documentation and their communication with nursing staff & GP’s in relation to the discharge of patients. A copy of this communication went to every Hospital Director (Registered Manager) and Matron (Appendix D). (ii) Resident Medical Officers (RMO’s) Within 5 working days of receiving the Regulation 28 report to prevent future deaths an urgent tele- conference was held with the Chief Executive and Medical Director of NES Healthcare (provider of RMO’s to Nuffield Hospitals), the Nuffield Health Quality Care Partner for North & Midlands (clinical contact) and the contract lead from Nuffield Health’s procurement team. Actions agreed and completed within 4 weeks were: ▪ All RMO’s received a copy of the correspondence sent to consultants. ▪ All RMO’s received a case study based on this event to reiterate their responsibilities in relation to communications with consultants, contemporaneous documentation and their communication with nursing staff & GP’s in relation to the discharge of patients (Appendix E). Registered Charity: 205533 (England & Wales) SC041793 (Scotland) Company Limited by Guarantee Registered in England 576970 ▪ Within the communication sent to RMO’s, it is made clear that they must escalate all abnormal investigation results to the consultant and clearly document this in the patient’s medical records. In addition, and further to learning from this event, information, clinical criteria & resource regarding antiphospholipid syndrome (APS) was also included. ▪ To provide robust and ongoing communications to this relatively transient workforce, NES Healthcare reviewed the RMO job description and strengthened the emphasis on responsibilities regarding escalation and communication of abnormal results to consultants and contemporaneous documentation (Appendix F). All current RMO’s have received a copy of the new job description, as will all future appointments. ▪ The clinical team at Nuffield Health reviewed the RMO Induction and Handbook to strengthen the emphasis on the above responsibilities (Appendix G (1 and 2)). (iii) Hospital teams Further to these communications, the Medical Director and Clinical Director/Chief Nurse sent a joint communication to all Hospital Directors (HD’s) & Matrons to reiterate the learning and actions taken following the inquest. This outlines the actions required at local level. (Appendix H). 5) The Admissions Policy for Nuffield Health Hospitals is being updated and in final draft. As an appendix to the policy, hospital teams will attach their local standard operating procedure (SOP) outlining inclusion and exclusion criteria for patients attending pre-operative assessment (POA) for elective surgery. This will be based upon the facilities at each hospital and service provision. Further to the learning from this event, it is recommended that should a patient present with a known diagnosis of APS, the admitting consultant must seek advice on a case- by-case basis from a consultant Haematologist before proceeding with treatment (Appendix I). With regard to abnormal platelet counts in the event of no known diagnosis of APS, we know from the investigation that the nursing team correctly escalated the low platelet count noted at POA, which is consistent with Nuffield Health Policy. For ongoing assurance, our established audit programme includes monitoring anaesthetic records to ensure abnormal results are highlighted. The consultant must be informed of any abnormal blood results noted during the patient’s stay; blood results are issued to the relevant clinical area from which the nursing team and / or RMO will receive and read them. The communications issued following this event to all medical personnel, with Matrons copied (for sharing with nursing teams) highlights this requirement and for the respective practitioner to make a contemporaneous medical record. Summary Mary’s unknown APS led to a very complex, unexpected and highly unusual clinical situation. The hospital team, and indeed the wider Nuffield community, have been very saddened by this tragic event. Immediately following Mary’s death, a local investigation took place at the Hospital with significant changes to mitigate future risk. This included the introduction of an additional step in Nuffield’s Registered Charity: 205533 (England & Wales) SC041793 (Scotland) Company Limited by Guarantee Registered in England 576970 protocol, this is to contact GP’s by telephone (in addition to sending the discharge summary) when there is an urgent action required of them. This in turn was included in the revised national discharge policy. Another key development in the Hospital was the introduction of electronic issue of discharge summaries via a secure portal, to give heightened assurance that information is received into GP surgeries within 48hrs of patient discharge. This system is in place in a small number of Nuffield Hospitals and we are looking to extend across all 31 locations. We now recognise further opportunities to improve quality and consistency of the discharge process through standardisation of systems, process and collaborative working with GP’s, which we are taking forward in our Quality Improvement Plan. The national policy originally developed in response to this event, included features intended as risk mitigation factors. The experience and outputs from the inquest have demonstrated the value of testing such documents with individuals and teams detached from (in this case the discharge) process to determine how clear the protocol really is to individuals less familiar with Nuffield Health systems and processes. This was a key piece of learning we shall apply to future policy developments. Reviewing the document with fresh eyes has, we believe, produced a more succinct policy with much greater clarity. This experience further highlights the complexity of multi-disciplinary working within the healthcare environment, and the critical nature of key fundamentals; verbal and written communications, for which all registered professionals, are individually accountable. The steps we have taken to reiterate this across all disciplines are hopefully clear within this response and the evidence provided. To gain assurance of ongoing standards and quality these aspects, along with other key indicators associated with the discharge process, are now more robust within our audit framework. Importantly, this involves not only a retrospective review of medical records, but also the patient’s experience. We sincerely hope that our response and the actions outlined in this report demonstrate and provide assurances to HM Coroner and Mary’s family that Nuffield Health have taken on board and acted upon the concerns raised in the Regulation 28 report to prevent future deaths. …………………………………………. Clinical Director and Chief Nurse Nuffield Health 01 December 2019 Registered Charity: 205533 (England & Wales) SC041793 (Scotland) Company Limited by Guarantee Registered in England 576970
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