Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0390, written 15 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Nov 2019 |
|---|---|
| Reference | 2019-0390 |
| Deceased | Francesca Sio |
| Coroner | Jonathan Landau |
| Coroner area | South London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 Greenbrook Healthcare Hyde Park Hayes 11 Millington Road 4th Floor, Building 3, Hayes, UB3 4AZ 2. Chief Executive Bromley CCG 379 Croydon Rd Beckenham BR3 3QL 1 CORONER I am Jonathan Landau, Assistant Coroner, South London jurisdiction 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 INQUEST On 29 April 2019 the court opened an investigation into the death of Francesca Margaux Sio. She died on 1 April 2017. The inquest was concluded on 8 November. I returned a conclusion of natural causes. The medical cause of death was: 1a Massive Pulmonary Tumour Embolism 1b Sacro-coccygeal Yolk Sac Tumour 4 CIRCUMSTANCES OF THE DEATH 1 Francesca died from a massive embolism caused by a previously undiagnosed tumour. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – Three days before she died, Francesca attended the urgent care centre in the grounds of Princess Royal University Hospital run by Greenbrook Healthcare. She waited nearly 4 hours to be assessed by a doctor and was then referred appropriately to the paediatric accident emergency department in the hospital. I heard unchallenged expert evidence during the hearing that mixing adult and child patients in urgent care centres risked children quietly deteriorating unnoticed. 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 10th January 2020. 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 following Interested Persons: Francesca’s family Greenbrook Healthcare 2 King’s College Hospital NHS Trust 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. 15 November 2019 9 Jonathan Landau, Assistant Coroner for South London 3
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.
Greenbrook Healthcare Building 3, Hyde Park Hayes 13 Millington Road Hayes, Middlesex UB3 4AZ Mr Landau Assistant coroner, south London. Croydon Coroner’s Office 2nd floor, Davis House Roberts St Croydon CR0 1QQ 7th January 2020 Dear Mr Landau I write in response to the Regulation 28, Prevention of Future Deaths report which you issued to Bromley Clinical Commissioning Group and Greenbrook Healthcare as a result of unchallenged evidence provided during the inquest of Francesca Sio. I would like to share my condolences with the family of Francesca during this very difficult time. Bromley CCG and Greenbrook Healthcare have prioritised their investigation into the issues raised in your report, we are responding jointly to the concern you raised which is: • A concern that mixing child and adult populations in a UCC creates a risk that children will quietly deteriorate unnoticed We note the acknowledgment in your inquest conclusion that the above concern did not affect the outcome for Francesca in any way, as she was appropriately referred into the Emergency Department and there was no evidence to suggest her condition deteriorated whilst she was in the UCC. We are sorry that we did not have representation in the inquest at the time when the paediatric expert witness gave her evidence. As a result, we could not provide immediate assurance to you that the potential risk, highlighted by Dr Bohin, is fully mitigated against within the UCC. Greenbrook Healthcare are an established urgent care provider managing 11 UCCs across London; working closely with Bromley CCG the service is continually scrutinised to ensure patient safety, of both adults and children, is paramount. The service we offer is in line with the national specification for UCCs (from NHS England) in which both children and adults with minor illness and minor injuries should be managed within a primary care led UCC. Registered office: Greenbrook Healthcare (Hounslow) Limited, Cardinal Square West, 10 Nottingham Road, Derby DE1 3QT. Company no.: 06025335 Greenbrook Healthcare Building 3, Hyde Park Hayes 13 Millington Road Hayes, Middlesex UB3 4AZ The UCC lies adjacent to the Emergency Department at Princess Royal University Hospital, walk in patients are assessed by a senior UCC streaming nurse and those with more serious conditions are navigated directly to the Emergency Department. Walk in patients with more minor presentations are managed within the UCC. There are clear pathways to transfer patients from the UCC into the Emergency Department at any time should their conditions deteriorate, or they require more specialist investigations. The pathways for transfers have been jointly developed by senior UCC and PRUH Emergency Department Clinicians and are monitored via the shared ED/UCC monthly clinical governance meeting. To ensure that children are managed safely in the UCC and do not deteriorate unnoticed the following systems are in place: • The UCC at Princess Royal University Hospital has a dedicated paediatric waiting room, child and adult populations do not sit in a shared waiting area (see attached photo). • All children have a nurse assessment within 15 minutes of arrival which includes a set of clinical observations (pulse, temperature, oxygen saturations). Children with abnormal or concerning observations on arrival are directed straight to the paediatric Emergency Department and are not kept waiting or managed within the UCC. • The UCC nurses making the streaming decision have all undergone Greenbrook’s streaming competency training program which includes specific training on assessing children. • All UCC clinicians, GPs and Nurse practitioners, complete the on-line training module “spotting the sick child”. • Greenbrook have a rolling monthly audit of streaming consultations to ensure all cases have clinical observations recorded and high-risk cases have been streamed directly to ED. The results of the audits are monitored through the monthly clinical governance meeting (this is a joint meeting with ED and paediatric ED). • Children managed within the UCC are, by definition, lower risk cases- typically those usually managed in a GP practice. The children streamed into the UCC are classed as urgent or routine, all urgent cases will be prioritised for full consultation, usually within an hour, which reduces the risk of deterioration in the waiting room. • Our average waiting times for a full consultation for children, after the initial clinical assessment, are between 1- 1.5 hours, occasionally our waiting times become longer, in such situations our escalation process is initiated, the shift lead nurse re-checks clinical observations on children (and adults) who have been waiting a prolonged time. Registered office: Greenbrook Healthcare (Hounslow) Limited, Cardinal Square West, 10 Nottingham Road, Derby DE1 3QT. Company no.: 06025335 Greenbrook Healthcare Building 3, Hyde Park Hayes 13 Millington Road Hayes, Middlesex UB3 4AZ • It is the role of the streaming nurse and shift lead nurse to visibly monitor the waiting room. The streaming room lies adjacent to the waiting area and has direct visibility of the adult and child waiting rooms. The senior nurses visualise patients in the waiting room every 10 minutes and re-assess patients who are showing signs of deterioration (e.g. increasing pain/distress, drowsiness). • In addition to waiting room supervision by the nurse practitioners, there is clear signage in the waiting room (see attached photos) asking patients or their carer to speak with the streaming nurse if they feel their symptoms are worsening. As an organisation we are keen to continually learn and improve our service. Greenbrook Healthcare worked in partnership with the paediatric team at Kings College Hospital NHS Trust in the Serious Incident investigation into the death of Francesca Sio. The investigating paediatricians were satisfied with the process for transferring Francesca and they did not raise any concerns about the UCC’s ability to monitor and identify deteriorating children. More broadly, the UCC has robust clinical governance processes in place which identify incidents of concern and ensures actions are taken to reduce risk of recurrence. In the 6 years that Greenbrook have managed the PRUH UCC there here have been no serious incidents relating to the deterioration of a child in the UCC waiting room. Bromley CCG have oversight of the governance processes. We hope the above gives you assurance that adult and child populations are not mixed in the UCC and there are effective systems in place to reduce the risk of a child deteriorating unnoticed within the UCC. We are not complacent, and we continually review our processes; we will be cognizant of your report when developing and reviewing our paediatric pathways to ensure the current high standards are continually maintained. Yours sincerely Dr Sally Johnson Group Medical Director Registered office: Greenbrook Healthcare (Hounslow) Limited, Cardinal Square West, 10 Nottingham Road, Derby DE1 3QT. Company no.: 06025335
INHS| Bromley Clinical Commissioning Group Assistant Coroner, South London. Global House Croydon Coroner's Office 10 Station Approach 2nd floor, Davis House Hayes Roberts St Kent Croydon CRO 1QQ BR2 7EH www.bromleyccg.nhs.uk Tel: 0203 930 0100 20 December 2019 Dear Mr Landau Re: Regulation 28: Prevention of Future Deaths: Francesca Sio, dec. Bromley Clinical Commissioning Group (BCCG) is in receipt of a Regulation 28, Prevention of Future Deaths report which you issued under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, issued as a result of unchallenged evidence provided during the Inquest of Francesca Sio in relation to deterioration of children whilst waiting to be seen. It is with great sadness that Francesca’s illness progressed so rapidly resulting in her death and my condolences are with the family at this very sad and difficult time as they adjust to life without her. Greenbrook Healthcare is an established urgent care provider managing 11 urgent care centres across London and has been commissioned by BCCG to provide community and primary care facilities to the local population against a contractual service specification which meets with NHS England requirements. In line with NHS England guidance, the urgent care centre is led by a general practitioner and in this case, is co-located within the Emergency Department (ED) at the Princess Royal University Hospital (PRUH). The types of patients that present to an urgent care centre are not in need of ‘emergency’ treatment but are those who that can be seen and treated by a general practitioner. All patients presenting to the PRUH ED are triaged and signposted to the service most relevant to their presenting complaint. The urgent care centre has a dedicated waiting area for children that is supervised by nursing staff who whilst are not paediatric specific staff members, do have appropriate training in the care and management of children. BCCG seeks assurance of compliance against the contractual commitments via regular formal contractual meetings with Greenbrook where performance reports, contractual reviews, key performance indicators are presented and scrutinised. Bromley CCG also reviews all serious incident reports and monitors the implementation of action plans at contract meetings with Greenbrook Healthcare. Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan 1 In addition, to local monitoring of performance against their contractual commitments, the service was inspected by the Care Quality Commission (CQC) to ensure compliance against their Key Lines of Enquiry (KLoEs) which consist of five domains; Safe, Effective, Caring, Responsive and Well-Led. Greenbrook Healthcare was last inspected by the CQC on 13 December 2017. Each of the domains was rated as ‘Good’. The findings of the CQC provide another level of assurance to the CCG. Bromley CCG has contracts in place for the provision of two Urgent Care Centres (UCCs) providing treatment for Bromley residents with minor injury & illness at Beckenham Beacon Hospital and the Princess Royal University Hospital (PRUH) both of which expire on 31st August 2020. The CCG is in the process of reviewing the options for re-procuring services at both sites from 14st September 2020 in line with the mandate from NHS England. As part of the re-procurement, the CCG will ensure that it gives due consideration to the concerns you have raised by the prevention of future deaths and welcome the opportunity to improve services in Bromley. Yours sincerely Dr Angela Bhan Managing Director NHS Bromley Clinical Commissioning Group A member of the NHS South East London Commissioning Alliance (Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark CCGs) Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan 2
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