Prevention of Future Deaths reports · 2019

Victor Hall

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 report16 Oct 2019
Reference2019-0482
DeceasedVictor Hall
CoronerRachel Syed
Coroner areaManchester (West)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedSalford Royal NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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 (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

Responses

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.

Response from Northern Care Alliance NHS Trust (PDF)
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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