Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0002, written 7 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jan 2020 |
|---|---|
| Reference | 2020-0002 |
| Deceased | Agnes Sansom |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | County Durham and Darlington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 Execitive Officer; and 2. Head of Nursing; of County Durham and Darlington NHS Foundation Trust 1 CORONER I am Jeremy Chipperfield, Senior Coroner for the area of Durham and Darlington 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 Twentieth August 2019 I commenced an investigation into the death of Agnes Gwenllian SANSOM, aged 95 The investigation concluded at the end of inquest on 6th January, 2020. The conclusion of the inquest was: I a Hospital Acquired Pneumonia I b Fractured Neck of Femur (Repaired) I c Frailty of Old Age II Left Ventricular Systolic Dysfunction, Stroke 4 CIRCUMSTANCES OF THE DEATH The deceased was admitted to University Hospital of North Durham on 15th July 2019. She was known to be at risk of falling and of suffering serious injury or death in the event of falling. The deceased was obliged to share a zimmer frame with another patient on the ward. On 18th July, a physiotherapist assessed the deceased and observed that she (i) was likely to rise from her bed and mobilise unaided (contrary to nursing advice); and (ii) required supervision when mobilising. These observations were recorded in the deceased’s “Patient Health Record” (a paper document). Had the physiotherapist’s observations been known to nursing staff or to the Ward Manager, action should have been taken to prevent unaided mobilisation. Nursing staff relied only upon the Electronic Patient Record System (EPRS) for information about the deceased. The EPRS contained none of the physiotherapist’s observations and no alert as the importance of the same. Neither nursing staff nor Ward manager acted to prevent unaided mobilisation. Unaided mobilisations continued after the physiotherapist’s assessment and during one such incident, on 20th July, the deceased fell, thereby sustaining the injury which led to her death. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows The following circumstances create the risk of other deaths: (i) existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it; and (ii) vulnerable patients are obliged to share walking aids on hospital wards 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 03 March 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 Chief Coroner and to the following Interested Persons: The family 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. 9 Jeremy Chipperfield Senior Coroner for Durham and Darlington 7.1.20
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.
INHS) County Durham and Darlington NHS Foundation Trust 4.0 MAK LUA! Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX E-mail: 2" March 2020 Mr. J. Chipperfield H.M. Coroners PO Box 282 Bishop Auckiand Co Durham DL14 4FY Dear Mr Chipperfield Re: Agnes Gwenilian Sansom | am writing in response to Regulation 28 Report To Prevent Future Deaths, which you issued to County Durham & Darlington NHS Foundation Trust on 6" January 2020. You raised two matters of concern that create the risk of other deaths and | will respond to each in turn. )) Existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it. The root cause analysis report has been reviewed and we have concluded that a misleading choice of words have been used as follows: “The matron advised that nursing staff primarily utilise Nervecentre (an electronic patient record) accessed by a hand held device as the main source of information during a shift rather than the patient's paper health record”. It is not factual to describe Nervecentre as an electronic patient record. The Trust does not have an electronic patient record in place. Nervecentre is an electronic observations system which is also used for some patient risk assessments; including falls risk assessment and mobility gallery. Detailed patient care records are multi-disciplinary and in paper format within the Trust. Both nursing and physiotherapy records, along with medical entries are recorded contemporaneously within the paper record. in relation to Ms Sansom the physiotherapist had recorded within the paper record, placed mobility advice above the bed and handed over this advice verbally to the nursing staff. On further discussion with the nursing staff they have confirmed that this is the accepted process, however, have also said that as Nervecentre is a hand held device they will on occasion refer to the mobility gallery within Nervecentre also. i NHS County Durham and Darlington NHS Foundation Trust To address this issue physiotherapists now record in the mobility gallery in Nervecentre if they identify change in mobility or change in interventions required. This does not replace the detailed paper record but ensures that all staff are aware of this whether accessing paper records or Nervecentre. “vulnerable patients are obliged to share walking aids on hospital wards” During traditional working hours walking aids are provided by physiotherapists following assessment of the patient. We have implemented a buffer stock of walking aids in the hospitals to ensure there is an adequate supply out of hours. Ideally the buffer stock should not be used as it is preferable that patients requiring a walking aid have a physiotherapist assessment first, however, if someone presents who does require a walking frame out of hours we have ensured that there is a buffer stock availabie for emergency use. | hope that you find the actions taken by the Trust to be adequate to address the issues that you have raised, but please do not hesitate to contact me if you require further information. Yours sincerely Executive Director of Nursing ce. CEO ledical Director sociate Director of Nursing, Patient safety
See every Prevention of Future Deaths report matching County Durham and Darlington NHS Foundation Trust, 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.