Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0037, written 25 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 | 25 Feb 2020 |
|---|---|
| Reference | 2020-0037 |
| Deceased | Beryl Holland |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State and the Chief Executive of the National Institute for Health and Care Excellence (NICE). CORONER lam Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South CORONER'S LEGAL POWERS | 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 10" July 2019, | commenced an investigation into the death of Beryl Holland. The investigation concluded on the 9" January 2020 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Hospital acquired pneumonia; 1b) Neck of femur fracture; 1c) Fall; Il) Myocardial infarction; type 1 diabetes, pressure ulcers, dementia. CIRCUMSTANCES OF THE DEATH Beryl Holland sustained a fractured neck of femur at the care home where she resided after a fall. She had poor skin integrity and was high risk in relation to pressure ulcers. She was admitted, via the Emergency Department, to Stepping Hill Hospital and operated on. Post operatively she continued to decline. She died at Stepping Hill Hospital on 7" July 2019. 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. — The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of. pressure ulcers developing in an Emergency Department setting. As aresult, _| Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 21* April 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, 3 COPIES and PUBLICATION | | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) MY daughter of the deceased; 2) Care Quality Commission, who may find it useful or of interest. | 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 | Alison Mutch OBE HM Senior Coroner 25.02.2020
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.
NICE Health and Care Excellence N | C E National Institute for 10 Spring Gardens London. SW1A 2BU United Kingdom +44 (0)300 323 0140 16 March 2020 Alison Mutch HM Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG a 17 MAR 2020 Your ref: 13303/RD HM CORONER Our ref: EH-305535 MANCHESTER SOUTH Dear Ms Mutch, I write in response to your correspondence, dated 25 February 2020, regarding the death of Beryl Hoiland. | was very sorry to read of Ms Holland’s death. We have reflected on the circumstances surrounding Ms Holland’s death, and the concerns raised in your report, relating to guidance on the managing and reducing the risks of pressure ulcers developing in an emergency department setting. The NICE guideline on the prevention and management of pressure sores (CG179) specifically provides advice to clinicians regarding patients receiving care in emergency department settings. Recommendations 1.1.2 and 1.2.1 contain advice to clinicians on risk assessment for patients receiving care in emergency departments if they have a risk factor, such as: significantly limited mobility (for example, people with a spinal cord injury) significant loss of sensation a previous or current pressure ulcer nutritional deficiency the inability to reposition themselves significant cognitive impairment. We therefore consider that NICE has produced relevant guidance and that no further action is required from us at this time in response to your report. We have initiated a multi-year programme of work called NICE Connect to review ail elements of the way we produce and present our guidance and advice. The aim of this quality improvement project is to transform the way NICE produces and presents information to users, to ensure it can be found on our website more quickly and easily and is as clear and accessible as possible. We will be working and consulting with stakeholders throughout this long-term project. Further details of this work can be found on our website. Yours sincerely, or Cua Sir Andrew Dillon Chief Executive www.nice.org.uk | nice@nice.org.uk
From Nadine Dorries MP
Parliamentary Under Secretary of State for Patient Safety,
Suicide Prevention and Mental Health
39 Victoria Street
London
SW1H 0EU
020 7210 4850
Your Ref: 13303/RD
Our Ref: PFD-1206650
Ms Alison Patricia Mutch
HM Senior Coroner, Manchester South
HM Coroner's Court
1 Mount Tabor Street
Stockport SK1 3AG
28th April 2020
Dear Ms Mutch
Thank you for your letter of 25 February 2020 to Matt Hancock about the death of Beryl
Holland. I am replying as Minister with responsibility for patient safety.
Please extend my sincere condolences to Ms Holland’s family and loved ones.
It is important that we look to make improvements where we can to ensure the highest
standards of quality and safety in the NHS and I am grateful to you for bringing these
matters to my attention.
I am aware that the National Institute for Health and Care Excellence (NICE) has advised
you in its response that a clinical guideline is available on the Prevention and Management
of Pressure Sores (CG1791) and that this guideline provides specific recommendations to
clinicians in relation to patients receiving care in emergency department settings if they
have a risk factor. It is the view of NICE that this guideline provides relevant guidance.
NHS trusts are expected to take into account NICE guidelines when developing Trust level
policies. Risk assessment and care planning for the prevention of pressure ulcers should
be undertaken in all relevant settings within a hospital and it is therefore expected that
emergency departments will have local policies in place.
To assist NHS trusts, in 2017, NHS Improvement published an emergency department
patient safety checklist2 that can be used to ensure skin assessments, appropriate care
plans and follow up care are undertaken and recorded. The checklist is endorsed by NHS
England, the Royal College of Emergency Medicine, and the Royal College of Nursing.
1 https://www.nice.org.uk/guidance/cg179
2 https://improvement.nhs.uk/resources/emergency-department-ed-patient-safety-checklist/
I am advised that the Stockport NHS Foundation Trust has adopted the Patient Safety
Checklist for use in the emergency department at Stepping Hill Hospital, alongside other
actions to improve processes around the identification and management of pressure
ulcers. The emergency department works closely with the Tissue Viability Nurse
Specialist and working together measures have been developed to improve patient safety
and the quality of care. For example, through improved access to dynamic mattresses
and the transfer of patients from a trolley to a bed if they are experiencing long waits and
are identified to be at risk.
I hope this response is helpful.
NADINE DORRIES
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