Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0021, written 4 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2020 |
|---|---|
| Reference | 2020-0021 |
| Deceased | Maureen Brown |
| Coroner | Emma Serrano |
| Coroner area | Derby and Derbyshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Derby and Burton 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. University Hospital of Derby and Burton; 2. NHS England; 3. Chief Coroner; 4. Family of the deceased. 1 CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of the Derby and Derbyshire. 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 the 12th November 2019, I commenced an investigation into the death of Mrs Maureen Ann Brown. The investigation concluded at the end of the inquest on the 3 February 2020. The conclusion of the inquest was a short narrative conclusion stating: “On the 1 June 2019 at the Coach House, Derby Road, Milford, Belper, Derbyshire, from a subdural haemorrhage caused by a fall whilst a patient at the Royal Derby Hospital. On being transferred from MAU to ward 405 information relevant to her falls risk assessment was known, but not recorded within the electronic transfer information. As a consequence ward 405 were not made aware of information which would have led the deceased having an increased supervision care bundle”. The cause of death was: 1a Subdural haemorrhage due to; 1b Fall. CIRCUMSTANCES OF THE DEATH 4 i) Mrs Brown was admitted to the Royal derby Hospital on the 16th April 2019. This was following a referral from her GP. This was for a urine sample showing pseudomonas, and the need for intravenous antibiotics. She was admitted under the Medical Assessment Unit (“MAU”) and transferred to ward 405. ii) Before her transfer, Mrs Browns’ daughter made the staff on MAU aware that Mrs Brown was increasingly confused due to the infection and may try and get out of her bed and as such was at an increased risk of falls. In addition, she disclosed that Mrs Brown had had a previous fall whilst she was a patient at the Royal Derby Hospital. iii) When a patient is ready for transfer an electronic handover is completed by the transferring ward. This is the only information that the receiving ward have access to at the point of accepting a patient to their ward. The 1 [IL1: PROTECT] information given by the Mrs Browns’ daughter, was not recorded in the electronic handover. iv) On being admitted to Ward 405 a Falls Risk Assessment was carried out, based on the information received from MAU. She was deemed to be a high risk of falls and falls preventions measures were put in place. These included bed rails and a call buzzer. She was placed onto a normal ward. However, had the information supplied by Mrs Browns’ daughter been included on the electronic transfer information, Mrs Brown would have been assessed as a high Risk of falls as well as needing an Increased Supervision Care Bundle. v) An Increased Supervision Care Bundle would have meant that Mrs Brown would have been put onto a ward with only 3 other patients, rather than a full hospital ward, and there would have been constant supervision by a nurse. vi) She subsequently fell from her bed. This caused her to suffer a bleed to the brain from which, she did not recover. vii) It was accepted by the Royal Derby Hospital that had Mrs Brown been on the Increased Supervision Care Bundle, it was more likely than it was not that she would not have fallen. 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. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred. Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded. 2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information. 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. 1. You may wish to consider the NHS policy and procedures for patient transfer. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 March 2020. 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. 2 [IL1: PROTECT] 8 COPIES and PUBLICATION I have sent a copy of my report to: 1. NHS England; 2. The Chef Coroner; 3. The University Hospital and derby and Burton; and 4. The family of the deceased. 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 04 February 2019 Miss Emma Serrano Assistant Coroner Derby and Derbyshire Coroners Area 3 [IL1: PROTECT]
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.
Miss E Serrano Assistant Coroner for Derby and Derbyshire Coroner’s Area St Katherine’s House St Mary’s Wharf Mansfield Road Derby Dear Miss Serrano, National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 8th February 2021 Re: Regulation 28 Report following the Inquest touching upon the death of Maureen Brown Thank you for your Prevention of Future Deaths Report (the “report”) dated 4th February 2019 concerning the death of Maureen Brown. I am sorry for the significant delay in our response. Please share my deep condolences with Mrs Brown’s family. The regulation 28 report concludes Mrs Brown’s death was a result of 1a Subdural haemorrhage due to; 1b Fall Following the inquest you raised concerns in your Regulation 28 Report to NHS England relating to the Trust and national handover processes. I understand that the Trust has responded to address the specific learning with regard their own internal patient transfer processes. In your report you express concern that “the national policy still states the only piece of information necessary for a transfer is the electronic transfer information”. I am assured by my colleagues at NHSX that there is a national Minimum Dataset (MDS) for transfers of patients between hospitals; Inter-Provider Transfer Administrative Minimum Data Set. This is overseen by NHS Digital. This does not relate to transfers of patients between wards within a single healthcare provider (a Trust in this case) and in such circumstances Trusts would be expected to have their own policies and protocols to govern the minimum data provided between departments to facilitate an effective transfer of patient information, following relevant clinical standards. On that basis, the actions taken by University Hospitals Of Derby And Burton NHS Foundation Trust would be relevant to your concerns. NHS England and NHS Improvement There is no national policy for a Minimum Dataset for inter-hospital transfers, as was the case in Mrs Brown’s care, and where these occur it would be incumbent on the Trust or provider to ensure they have robust handover and transfer of information procedures. My Regional Colleagues have had assurance from the Trust of the changes they have made and the response to learning that has been implemented. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director
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