Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0482, written 16 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 | 16 Oct 2019 |
|---|---|
| Reference | 2019-0482 |
| Deceased | Victor Hall |
| Coroner | Rachel Syed |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Salford Royal NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD 2. Dr June Raine CBE, The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA), 151 Buckingham Palace Road, London SW1W 9SZ 3. The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London W1B 1PZ CORONER I am Rachel Syed, HM Assistant Coroner for the Coroner Area of Manchester West. 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. INVESTIGATION and INQUEST On the 16th January 2019, I commenced an Investigation into the death of Victor James Hall, born on the 24% May 1934. The Investigation concluded at the end of the Inquest on the 16" October 2019. The medical cause of death was:- Ia Cardiac enlargement and coronary artery atheroma in combination with Chronic Obstructive Pulmonary Disease (COPD). The conclusion of the Inquest was that Mr Hall died from natural causes. CIRCUMSTANCES OF THE DEATH 1. Victor James Hall (hereinafter referred to as “the deceased”) died at the Salford Royal Hospital on 29" June 2018. The deceased suffered from a number of underlying co-morbidities, namely Bronchiectasis, Chronic Obstructive Pulmonary Disease and Heart Disease and was fitted with pacemaker around 2010. . On the 2 5 June 2018, the deceased was admitted to the Salford Royal Hospital with shortness of breath and an exacerbation of his Chronic Obstructive Pulmonary Disease. Mr Hall was diagnosed with Acute Kidney Injury and prescribed, 500mg of IV sodium bicarbonate, 1.4% every six hours. » A member of the pharmacy dispensing team, in error, manually dispensed Phosphate Polyfusor which was close to the sodium bicarbonate Polyfusors box and generated a label for Sodium Bicarbonate. The Pharmacist tasked with checking the dispensed medication, failed to identify the error, by checking the medication packaging against the prescription and label and authorised release for delivery to the Wards. 5. Two Ward Nurses, both responsible for checking and signing the prescription chart, failed to check the medication packaging, against the prescription and label and at around 23.30 on 28 June 2018, Mr Hall was infused with Phosphate Polyfusor. At approximately 01.20 on 29% june 2018, Mr Hall was found to be unresponsive and the Resuscitation Team was summoned. Despite resuscitation efforts, Mr Hall died on the same day. 6. The Post Mortem and Toxicology evidence concluded that Mr Hall could have died at any time from his underlying heart, lungs and kidney conditions and the medication error was not in keeping with levels associated with fatalities therefore had played no role in his death. 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: During the Inquest, evidence was heard that:- 1.Salford Royal Hospital had undertaken an internal investigation and concluded that one of the root causes for the medication error, was the Phosphate Polyfusor product design. i, The Pharmacy and Nursing Matron Lead, concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label. Salford Royal Hospital, wrote to the Medicines and Healthcare products Regulatory Agency (MHRA) in 2018, requesting the word Polyfusor be removed from the Phosphate design product packaging to prevent future medication errors. Despite repeated requests from Salford Royal Hospital for an MHRA update, the product design for Phosphate Polyfusor remains the same. 2. I request that The Chief Executive, Medicines and Healthcare products Regulatory Agency (MHRA) reviews the: i. Product design on the Polyfusors in question 3.The Chief Executive, Nursing & Midwifery Council, 23 Portland Place, London No W1B 1PZ reviews the: i.Guidance given to their members in relation to the administration of medication to consider and include the simplest of steps, namely that a Healthcare Professional should check the name of the medication on the prescription chart against the name of the medication on the packaging and labelling of the medication at the time of each administration of medication to ensure that the correct medication is always administered to a patient. ii.Guidance given to their members in relation to their duties, to accurately record and contemporaneously document the packaging, label an prescription checks they have undertaken to ensure the correct medication is always administered to a patient. 4.The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford M6 8HD reviews the: i,Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgement of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient. ii. Training, Auditing, Supervision and monitoring of all staff, particularly Nursing and Pharmacy staff, in relation to the above issues. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that 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 11 December 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. COPIES and PUBLICATION T have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. | | Son of the deceased 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. Dated 16" October 2019 Rachel Syed HM Assistant Coroner
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.
Chris Brookes Chief Medical Officer/Deputy Chief Executive Group Headquarters 3rd Floor Mayo Building Stott Lane Salford M6 8HD Telephone: 0161 206 4657 Ref: CB Date: 9.12.19 The Coroners Office Paderborn House Howell Croft N Bolton BL1 1QY Via email only Dear Ms Syed Re: Victor Hall (Deceased) I write following the conclusion of this inquest on 16th October 2019. At the outset please accept my sincere condolences to the family of Victor Hall. I am sorry that they have been given cause for concern at such a difficult time. Thank you for bringing the concerns raised to my attention The Trust is dedicated to ensuring patient safety is maintained throughout all services. I would like to take this opportunity to provide assurance to both you and the family that the Trust takes the concerns raised very seriously and have conducted a thorough review into the concerns raised. I have set the concern to The Chief Executive, Salford Royal Hospital, NHS Trust Hospital, Stott Lane, Salford, M6 8HD out in bold below: i. Guidance and procedures in relation to the dispensing and transfer of medications from the Pharmacy Department to a ward, to include a system of checking medications against the packaging, labelling and prescription chart at the time of receipt by the ward. Furthermore, to consider documentary evidence of the fact that the medication packaging has been checked against the prescription chart and an acknowledgment of receipt of the correct medication by the pharmacy and ward staff, evidenced by a signature of the recipient. In response to the issues raised a full review of the dispensary environment at Salford Royal Hospital will be undertaken. This review will look at the workspace design and the processes involved in the dispensing and checking of medication in the pharmacy department with the aim of reducing noise and distractions. I have set out the Trust’s action plan to achieve this below: Action Preventing staff entering the dispensary unless they have a relevant reason to be in there and so minimise the risk of interruption. This will be enforced with signage and staff awareness at daily huddles. Introducing library conditions within the dispensary. Changing the exit route (after 5pm) from the department which is currently located next to the accuracy checking area. Staff will exit the department via the pharmacy reception exit, preventing staff using the dispensary as a thoroughfare. Arranging feedback sessions for all staff to highlight elements of the clinical check, dispensing and accuracy check processes that need to be improved. Staff will be made aware of this at daily huddles. Reviewing the layout of the dispensary with the aim of separating the areas used for different parts of the dispensing process and improving the flow of work. Implementing “closed loop dispensing” (linking the electronic prescribing system to the pharmacy dispensing system and robot) with the aim of reducing dispensing errors and improving efficiency and therefore reducing the number of staff needed in the dispensary. Action Lead Completion By 31st January 2020 Commencing with immediate effect. 31st January 2020 31st January 2020 29th February 2020 30th June 2020 Changes will be made to the processes involved in administering medication by both the nursing and pharmacy staff to inpatients at Salford Royal NHS Foundation Trust by: Action Lead Digital Team Completion By 30th June 2020 Action Implementing “closed loop medication administration” (electronic barcode scanning of patients and medications) to ensure that patient’s receive the right drug at the correct dose by the right route at the intended time. This will indicate to nursing staff (at the point of administration rather than the point of receipt) that the prescribed medication has been correctly sourced. i. Training, Auditing, Supervision and monitoring of all staff, particularly nursing and pharmacy staff, in relation to the above issues. We acknowledge as a learning organisation that we need to review our training and supervision for both our nursing and pharmacy staff. The pharmacy department will ensure the following actions will be taken: Action Lead Action Updating the accuracy checking procedure which will incorporate a second check for all intravenous fluids. Introducing an electronic sign off to indicate that key procedures have been read and understood by relevant staff. Reviewing the number of items required to complete dispensing and accuracy checking logs during induction. Introducing a formal revalidation procedure for staff involved in dispensing errors Introducing a recurrent accuracy checking log for all accuracy checkers to ensure competence. Identifying formal supervisory duties and responsibilities in the dispensary. Analysing near miss data to identify common dispensing errors and introducing on-going communication of this to staff. Reviewing the accuracy checking test to incorporate a wider range of medications. Monitoring of compliance of medicines safety training completed by nursing staff on Ward H2. Monitoring of medicine safety incidents on ward H2 Policy to be published about the process to follow when involved in a medicines safety incident. All nursing staff to be made aware that there are many different types of Polyfusor products. In order Completion By 31st December 2019 31st December 2019 31st December 2019 29th February 2020 29th February 2020 29th February 2020 29th February 2020 29th February 2020 Commenced Commenced 29th February 2020 29th Feb 2020 to prevent errors all details must be checked in full as per any medication. Implementation by the Learning and Development team learning from this incident within the medicines learning package. 31st December 2019 In addition the nursing staff recognise that there are lessons to learn and will ensure that the following actions are taken: Deborah Hindle, Deputy Director of Nursing for the Integrated Care Division will ensure that all nursing staff on ward H2 are compliant with their medicines safety mandatory training. Deborah Hindle will monitor medicines safety mandatory training and ensure all staff are compliant. Weekly senior nurse walkabouts will include ward H2, where observations will be undertaken of nursing medication/fluids dispensary checking procedure. A policy will be published to provide guidance about the process to follow if a member of staff is involved in a medicine safety incident. This will provide instruction to clinical staff about the framework of processes for all aspects of medicines management including the administration of medication. It will also provide guidance on whether staff need to repeat their medicines management workbook. The senior nursing staff will be responsible for the dissemination of the policy, monitoring the implementation and adherence to the policy. I do hope the above gives assurance that the concern raised the Trust has recognised and taken the concerns raised seriously and taken prompt steps to ensure lessons have been learnt. I would like to conclude by offering my personal apologies to Victor Hall’s family for their sad loss and would like to reiterate that we are committed to embedding the learning from this case to ensure ongoing improvements to patient care at the Trust Yours sincerely Consultant Emergency Medicine Executive Medical Director, Salford Royal NHS Foundation Trust Chief Medical Officer and Deputy Chief Executive Northern Care Alliance (Incorporating Salford Royal NHS Foundation Trust and Pennine Acute NHS Trust)
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