Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0102, written 23 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2020 |
|---|---|
| Reference | 2020-0102 |
| Deceased | Gordon Fenton |
| Coroner | Adrian Farrow |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust · Pennine Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Director, Tameside and Glossop Integrated Care NHS Foundation Trust, Tameside General Hospital, Fountain Street, Ashton-under-Lyne, Lancashire, OL6 9RW 2. Director, Pennine Care NHS Foundation Trust, 225 Old Street, Ashton-under Lyne, Lancashire, OL6 7SR 1. CORONER I am Adrian Farrow, Assistant Coroner, for the Coroner Area of Greater Manchester South 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made (Investigations) Regulations 2013 the Coroners and 29 of 3. INVESTIGATION and INQUEST On 1st July 2019 an investigation was commenced into the death of Gordon Fenton, aged 70. The investigation concluded on the 6th March 2020 and the conclusion of the inquest by the jury was that the medical cause of death was: 1a. Pulmonary embolism 1b. Deep Vein Thrombosis 1c. General Debility II. Urinary Tract Infection. In summary, the findings of the jury were that Mr Fenton died at Tameside General Hospital on 29th June 2019, having been admitted there on 22nd May 2019. He was subject to detention under the Mental Health Act 1983 on the Hague Ward (Pennine Care NHS Foundation Trust) and, periodically at Tameside General Hospital (Tameside and Glossop Integrated Care NHS Trust). The jury found that the quality of information sharing between the two NHS Trusts was inadequate and prolonged the treatment of the urinary tract infection and that the interaction and engagement between the medical professionals and urology department led to ineffective treatment for Mr Fenton. The narrative conclusion of the jury was that Mr Fenton died in hospital whilst he was detained under the Mental Health Act from complications which arose in the course of treatment for urinary tract infection in which treatment was ineffectively managed between the mental health and medical wards 1 4. CIRCUMSTANCES OF THE DEATH Mr Fenton was a fit and active 70 year old. He had a history of mental illness stretching back to his early adult life, but there had been no recent significant psychiatric history. He had an enlarged prostate and was prescribed medication for it. On 14th May 2019 due to urinary retention, he was referred by his GP to Tameside General Hospital (“TGH”), where a catheter was inserted. He reattended at TGH on 16th May and was admitted overnight due to a urinary tract infection before being discharged home. By 20th May, Mr Fenton had suffered a serious deterioration in his mental state and he was referred back to TGH where a diagnosis of possible delirium or acute mental health problems was made and with intervention from the Pennine Care Trust (“Pennine Care”) psychiatric team, he was discharged home again on 21st May with a view to care by the community mental health and district nursing teams. On 22nd May, Mr Fenton’s mental health had further deteriorated and he was admitted back to TGH and placed under a s3 Mental Health Act section by Pennine, where he was transferred. Although located on the same site, TGH and Pennine Care operate in separate buildings and as separate Trusts. The staff on Hague ward (Pennine Care) were primarily trained in psychiatric and mental health rather than medical care. In particular, they did not routinely deal with acute medical problems or the specific management of patients fitted with catheters and in particular, did not undertake trials without catheter or change catheters. A trial without catheter was advised by TGH microbiologist on 6th June, but this did not take place because of the absence of expertise on Hague Ward. Mr Fenton was transferred to A&E at TGH on 7th June when blood was observed in his catheter bag. He was treated and returned to Hague Ward on 8th June. On 9th June, blood was observed in the catheter bag again and in accordance with correspondence between Hague Ward and the TGH Urology department (to whom Mr Fenton had been known since 2016) he was seen in the urology clinic on either 10th or 11th June when a further attempt of trial without catheter was advised to be undertaken. The Consultant on Hague ward felt unable to make a firm diagnosis of Mr Fenton’s mental health until progress was made in treating the urinary tract infection, which could have been an underlying or contributing cause. On 11th June, Mr Fenton, in a state of distress, removed his own catheter. He was again transferred from Hague ward to TGH A&E, where he was subsequently admitted and was placed on Ward 31, where he stayed until 20th June. He had 1:1 care from the Hague ward staff whilst on ward 31 at TGH, but that was not 24-hour cover. A trial without catheter was attempted on 18th June, but that was unsuccessful. The replacement catheter was of a size which the consultant urologist confirmed may have contributed to the continuation of the urinary tract infection. The evidence was unclear as to whether a similar-sized catheter had been inserted in A&E at TGH after Mr Fenton had removed the catheter on 11th June. Hague ward were resistant to Mr Fenton returning to them without input from the urology department. The on-call urology registrar, acting on the information provided by ward 31 advised that the catheter remain in place until Mr Fenton was seen at the scheduled haematuria clinic appointment on 25th June. On that basis, Mr Fenton was transferred back to Hague ward. Mr Fenton’s behaviour was problematic. On 25th June, at the haematuria clinic, the catheter was found to be inappropriately small in size and blocked. His prostate was inflamed. A 2 longterm, large gauge catheter was fitted with a plan to have a trial without catheter after 3 months. A urine sample revealed continuing urinary tract infection. On 27th June, Mr Fenton slipped off the bed in Hague ward and fell during a family visit, banging his head. He was transferred to TGH A&E for a CT scan and assessment. Although the CT scan was clear, there were signs of urosepsis. He was transferred into the care of the Acute Medical Unit and blood samples revealed serious infection and urinary retention. His condition was monitored and treatment given for the infection, but at about 2.55am on 29th June, Mr Fenton suffered a seizure and then went into cardiac arrest and died. The post-mortem autopsy revealed a pulmonary embolism which had originated in a deep vein thrombosis in Mr Fenton’s right calf, which had arisen as a consequence of the general debility from the period of urinary infection. 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. The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems. 2. There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts. 3. There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient’s needs. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 18th June 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 3 I have sent a copy of my report to the Chief Coroner and to family. on behalf of the 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. Adrian Farrow HM Assistant Coroner 23.04.2020 4
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.
Corporate Services Trust Headquarters 225 Old Street Ashton-under-Lyne Lancashire OL6 7SR Telephone: 0161 716 3000 9th July 2020 PRIVATE & CONFIDENTIAL Mr A Farrow HM Assistant Coroner Coroners Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Farrow RE: Mr Gordon Fenton Thank you for your Regulation 28 Report dated 23rd April 2020 and for bringing to my attention the concerns you have after hearing evidence at the inquest of Mr Gordon Fenton. Your concerns have been reviewed jointly between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Foundation Trust. Pennine Care’s response is outlined below: Concerns: • The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems. • There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts. • There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient’s needs. Response: We are very sorry if this was the impression projected to you, the jury and Mr Fenton’s family at inquest. We hope that you will accept from this response that both Tameside & Glossop Integrated Care NHS Foundation Trust (TGICFT) and Pennine Care Foundation Trust (PCFT) are committed to working together to improve the safety of all patients requiring psychiatric care who also have acute medical problems. It is accepted that, at the time of time of Mr Fenton’s care, there were existing processes that required improvement in terms of shared physical and mental health care. As part of our investigation into your concerns, extensive discussions have taken place between Tameside’s Associate Director and Mental Health Quality Lead at PCFT and the Head of Assurance and Governance and Lead Nurse for Mental Health and Learning Disabilities at TGICFT in relation to ongoing improvements in shared service, specifically in relation to creating a formal standard operating procedure and enhancing services offered by TGICFT. It is understood that it was discussed in evidence that both organisations have been working towards creating a joint Standard Operating Procedure (SOP) for older people receiving in-patient mental health care and treatment on our older people’s wards who require medical input. It is recognised that these patients will often have the most complex comorbid physical and mental health needs and, therefore, it is extremely important that there must be a shared responsibility between mental health services and acute services to ensure all patients have timely access to specialist advice and are provided with safe and effective care. This SOP will apply to all patients within PCFT’s Tameside older peoples’ mental health in-patient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers and Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot, in the first instance for eight weeks, which will then be reviewed by both organisations to establish a more formal offer and outcomes. It is hoped that, if this procedure is successful, that similar processes will be developed for all of our patients requiring shared input. A number of pathways have also been created with regards to mental health in- patient transfers of care and return in-patient transfers of care. In terms of transfers of care, the process will be split into three categories; 1. Patients with an acute deterioration of their physical health, 2. Patients with a chronic long-term condition who may be deteriorating or for ongoing management advice and; 3. Gathering of required information either at the point of admission or transfer back from TGICFT. The process will include PCFT staff performing baseline physical observations and calculating the National Early Warning Score (NEWS), following which, if deemed necessary they will refer the patient to the medical team/on-call doctor and handover the patient’s clinical presentation. At this time, PCFT will assess whether further assistance is required from the Digital Health Services to coordinate access to specialist services for review and to agree an appropriate management plan. If the patient does need immediate on-going physical health support, the nurse-in-charge will contact Digital Health to complete a full physical and mental health assessment to determine whether the patient requires admission to a medical ward. The Digital Health Team will be responsible for coordinating direct admission to a medical bed, however if an attendance to the Emergency Department (ED) is required, Digital Health will liaise directly with the ED Team Leader and complete a ‘Situation, Background, Analysis and Recommendation’ (SBAR) handover. PCFT will be responsible for informing the Mental Health Liaison Team of patient transfers to TGH. Once a patient is deemed medically fit for discharge, TGICFT’s ward team will contact PCFT MH Liaison Team to provide a full handover of nursing care and agree patient outcomes, including on-going care and treatment. Included in this handover will be details of bloods completed within the preceding 24 hours. The appropriate PCFT junior doctor will then be asked to attend the medical ward as a matter of urgency to assess the patient’s suitability for transfer back to PCFT and arrangements made by PCFT MH Liaison Team to transfer the patient to Summers or Hague Ward. Due to concerns raised as a result of Mr Fenton’s inquest, the SOP has reinforced that all patient’s with on-going care and treatment needs must be clearly defined and communicated to the receiving Mental Health Team to ensure safe transfer of care takes place. This will be accompanied by a discharge summary and prescription information that should already be provided under the current process. In the absence of any additional required information PCFT will liaise with the Digital Health Team who can access this information on their behalf. We are confident that the new SOP will support our clinical teams in early identification of patients who may be experiencing an acute physical health deterioration and early intervention and prevent any unnecessary attendance for those patients at the Emergency Department (ED), or multiple moves for those older people currently an in-patient on Summers and Hague Wards. It is also anticipated that this will support signposting, including ongoing care and treatment of patients with chronic long-term conditions who require specialist services, as well as assisting with planned transfer of patients returning to our in-patient wards following a period of care and treatment within TGICFT in-patient services. Please note that this SOP remains in its implementation stages as both Trusts are working to align their own pathways with the new arrangement. It is planned that his will go live at the end of August 2020. Once the new SOP is approved by both Trusts, self-directed training will be carried out by all staff to which the SOP is relevant and this training will be documented in their training record. It should be noted that this new process will not replace current appropriate intervention that must be provided for all physical health needs as detailed in PCFT’s Physical Health Policy for Mental Health & Learning Disability Service Users (CL042). This policy was effective at the time of Mr Fenton’s admission and outlines expected standards to ensure that physical health care, appropriate to the needs of the individual, is delivered and identified appropriately prompting appropriate action. Similar to the proposed SOP, PCFT perform baseline physical observations and calculate the national early warning score. Any abnormal results, concerns or potential problems highlighted will require either further assessment by ward staff to gather more information to define the problem and inform care, or immediate referral to a doctor or specialist practitioner. Where emergency admission or treatment is required, staff should utilise medical practitioners available throughout a 24 hour period through the on-call system, crash teams and/or 999 as appropriate. including BMI, wounds, It should be noted that, where possible, every PCFT patient is assessed using an in-patient physical health screening tool within 24 hours of their admission. Where it is not possible to complete the physical health screen within 24 hours, regular attempts to complete are made and documented. This assessment takes into consideration a number of clinical factors falls, venous infection, mobility thromboembolism, pain, fluid intake etc. Any abnormal results, concerns or potential problems highlighted will require either further assessment by ward staff to gather more information to define the problem and inform care, or immediate referral to a doctor or specialist practitioner. This is also discussed by the multi-disciplinary team and reviewed during ward rounds or other MDT meetings. When transfers to a ward outside of the organisation takes place, physical health monitoring and examination information should be reviewed, this should also be incorporated into the transfer of care documentation. including risk of The teams on Summers and Hague Wards are currently using Digital Health for advice and guidance with regards to mental health patients requiring medical input. It is planned that the updated process and outcome of Mr Fenton’s inquest will be presented at the Tameside & Glossop CCG Bi-Lateral PCFT Mental Health Contract Quality and Performance Group. One of the main purposes of the performance group is to provide education around improvements in patient care at the Trust and to ensure the implementation of the resulting action plans. This will be placed on the group agenda and discussed once pressures surrounding COVID-19 have eased. The outcome of the inquest and subsequent learning will also be presented at the Tameside Borough Quality Governance and Shared Learning Forum with any subsequent actions to be monitored. PCFT are confident that, following communications and implementation of the new joint SOP and contingency measures in place, that there will be no reason as to why both Trust’s should deviate from recommended guidance or result in the same omissions that occurred in Mr Fenton’s journey. I hope this response assures you that the Trust has taken your concerns seriously and is taking joint measures to address these. Yours sincerely Medical Director/Deputy Chief Executive E:
r,•1:kj Tameside and Glossop Integrated Care NHS Foundation Trust Chief Executive Officer Silver Springs Fountain Street fas hton-under-Lyne Lancashire OL69RW 10th July 2020 Mr Adrian Farrow HM Assistant Coroner Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK13AG Dear Mr Farrow, Regulation 28: Report to prevent future deaths, following the Inquest touching upon the death of Mr Gordon Fenton I am writing to you in respect of your letter dated 23rd April 2020, by way of a Regulation 28 Report issued following the Inquest touching upon the death of Mr. Gordon Fenton, which concluded on 6th March 2020. I hope to be able to address the concerns raised in your report and set out_ below my response which has been compiled further to joint working between Tameside and Glossop Integrated Care NHS Trust (TGICFT) and Pennine Care Foundation Trust (PCFT). Concern 1: The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems. I am very sorry if this was the impression projected to you, the jury and Mr Fenton's family at inquest. I hope that you will accept that both TGICFT and PCFT are committed to working together to improve the safety of all patients requiring psychiatric care, who also have acute medical problems. mm disability ffl~ rnnfinPnt Chief Executive - Chair ,~1:;.1 Tameside and Glossop Integrated Care NHS Foundation Trust As you may already be aware, TGICFT have obtained a copy of the court recording. This has been reviewed by the Trust and has identified areas of learning in terms of providing evidence at Coroner's Court and the importance of continuity, even where there may be a difference of opinion as to the expectations of each service. Please note that TGICFT are not commissioned by the Clinical Commissioning Group to provide in-reach services to Mental Health Wards, it is accepted that at the of time of Mr Fenton's care, there were existing processes that required improvement in terms of shared physical and mental health care, which have been detailed below. Concerns 2 and 3: There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts. There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs. As part of our investigation into your concerns, extensive discussions have taken place between the Associate Director and Mental Health Quality Lead at PCFT, Head of Assurance & Governance for TGICFT and Lead Nurse for Mental Health & Learning Disabilities at TGICFT in relation to ongoing improvements in shared service, specifically in relation to creating a formal standard operating procedure and enhancing services we offer. I understand it was discussed in evidence that we have been working towards creating a joint Standard Operating Procedure (SOP) for older patients receiving mental health care and treatment from PCFT who require medical input. It is recognised that these patients will often have the most complex comorbid physical and mental health needs, therefore it is extremely important that there must be a shared responsibility between mental health services and acute services to ensure all patients have timely access to specialist advice and are provided with safe and effective care. The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot in the first instance for 8 weeks, which will then be reviewed to establish a more formal offer and outcomes. It is hoped that if this procedure is successful that similar processes will be developed for all of our patients requiring shared input. A number of joint pathways have also been created with regards to Mental Health Inpatient Transfers of Care and Return Inpatient Transfers of Care. In terms of transfers of care, the process will be split into three categories; ~= disability mr. rnnfirJpnt Chief Executive Chair- I- r.!7:b1 Tameside and Glossop Integrated Care NHS Foundation Trust Patients with an acute deterioration of their physical health, Patients with a chronic long-term condition who may be deteriorating or for ongoing Gathering of required information either at the point of admission or transfer back 1. 2. management advice and; 3. from TGICFT. I understand that the process will include PCFT performing baseline physical observations and calculating the National Early Warning Score (NEWS), following which, if deemed necessary they will refer the patient to PCFT's medical team/on call Doctor and handover clinical presentation. At this time, PCFT will assess whether further assistance is required from the Digital Health Services to coordinate access to specialist services for review to agree an appropriate management plan. If the patient does need immediate on-going physical health support, the Nurse in Charge will contact Digital Health to complete a full physical and mental health assessment to determine whether the patient requires admission to a medical ward. The Digital Health Team will be responsible for coordinating direct admission to a medical bed, however if an attendance to the Emergency Department (ED) is required, Digital Health will liaise directly with the ED Team Leader and complete a 'Situation, Background, Analysis and Recommendation' (SBAR) handover. PCFT will be responsible for informing the Mental Health Liaison Team of patient transfer to TGH. Once a patient is deemed medically fit for discharge, our Ward Team will contact PCFT MH Liaison Team to provide a full handover of nursing care and agree patient outcomes, including on-going care and treatment. Included in this handover are bloods completed within the preceding 24 hours. The appropriate PCFT Junior Doctor will then be asked to attend the medical ward as a matter of urgency to assess the patient's suitability for transfer back to PCFT and arrangements made by PCFT MH Liaison Team to transfer the patient to Summers or Hague Ward. I am confident that the new joint SOP will support PCFT clinical teams in early identification of patients who may be experiencing an acute physical health deterioration and early intervention and prevent any unnecessary attendance for those patients at the Emergency Department (ED), or multiple moves for those older people currently an in-patient on Summers and Hague Ward. It is also anticipated that this will support signposting, including ongoing care and treatment of patients with chronic long-term conditions who require specialist services, as well as assisting with planned transfer of patients returning to PCFT following a period of care and treatment within our inpatient services. Once the new SOP is approved by both Trusts, self-directed training will be carried out by all staff to which the SOP is relevant and this training documented in their training record. I understand that in the meantime PCFT are using our Digital Health Team for advice and guidance with regards to mental health patients requiring medical input. It is planned that the updated process and outcome of Mr Fenton's inquest will be presented at our Divisional Governance Meetings and also reported to the Service Quality & ICJ= disability I 8 [?ii rnnftrlPn; Chief Executive Chair Fi't:b1 Tameside and Glossop Integrated Care NHS Foundation Trust Operational Governance Group (SQOGG), with any subsequent actions to be closely monitored. Both Trusts are confident that following communications and implementation of the new joint SOP will address the concerns raised and minimise the likelihood of similar occurrences taking place and to enable both Trusts to provide safe and effective care to all our patients. I hope your concerns have been addressed, however should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact me. Director of Nursing and Integrated Governance In the absence of the Chief Executive IClrl disability I mr. rnnfirlpnt Chief Executive - Chair -
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