Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0132, written 25 Jun 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 Jun 2020 |
|---|---|
| Reference | 2020-0132 |
| Deceased | Winifred (Mary) Redfearn |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
David Ridley HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Kevin McNamara Esq. Chief Executive Officer The Great Western Hospital NHS Foundation Trust Marlborough Road Swindon SN3 6887 CORONER I am David Ridley, Senior Coroner for Wiltshire and Swindon 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. http://www.legislation.gov. u k/ukpga/2009/25/schedu le/5/paragraph/7 http://www.legislation.gov .uk/uksi/2013/1629/part/7 /made 3 INVESTIGATION and INQUEST On the 21 January 2020 I commenced an investigation into the death of Winifred Mary Redfearn, otherwise known as Mary Redfearn and the 24 January 2020. On 19 June 2020 I concluded Mary's Inquest finding that the medical cause of death was:- I then went onto open her Inquest on 1a) Pulmonary thromboembolism b) Deep vein thrombosis c) Immobility due to head and neck injuries due to fall 2 ) lschaemic heart disease I recorded how, when and where Mary came by her death as follows: - Winifred who was known by her middle name Mary died on the morning of 15 January 2020 at the Great Western Hospital in Swindon. A post mortem revealed that she died from a pulmonary embolism caused by a deep vein thrombosis attributable to her immobility in hospital after she was admitted to hospital following a fall down the stairs at home on 8 January 2020. As a result of the fall she injured her head and neck. Mary also had ischaemic heart disease which more likely than not contributed to her death. CONCLUSION - Accident 4. CIRCUMSTANCES OF DEATH I was satisfied on a balance of probabilities that the incident resulting in Mary's attendance at the Great Western Hospital occurred when she fell down the stairs at her home on Wednesday 8 January 2020. She attended the emergency department at the Great Western Hospital on Thursday 9 January 2020 at 2323 hours and was admitted the followin da . As part of the nd noted that evidence I had a statement from Locum Senior House Officer, Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP Tel 01722 438900 I Fax 01722 332223 mid-afternoon on 10 January 2020 as a result of a planned CT scan of the whole body the decision was taken to withhold venous thromboembolism prophylaxis. The CT scan was completed and reported the same day at 1922 in respect of which the injury, in particular to her spine at C6, C7 was revealed. The Pathologist, found at post mortem that the cause of Mary's death was as a result of developing a deep vein thrombosis as a result of immobility which then led to the Having reviewed development of pulmonary thromboembolism statement, I noted that despite the involvement of 3 other doctors on the evening of the 10 January 2020 that it was not until the afternoon on Monday 13 January 2020 was a request made to resume Dalteparin as part of the venous thromboembolism prophylaxis. from which she died. 5. CORONER'S CONCERNS I had no evidence before me to say more likely than not that it would have made a difference and having dealt with many cases similar to this, I fully recognise that even with venous thromboembolism prophylaxis, the risk of developing a deep vein thrombosis and subsequent pulmonary thromboembolism can never be completely excluded. That having been said I am, however, somewhat concerned that the resumption of Dalteparin took in excess of 2½ days from the production of the CT report and the delay would appear to be solely attributable to the weekend separating the point of which the Dalteparin was stopped and when it was resumed on Monday afternoon. Whilst I accept it may not have made a difference in this particular case, I am concerned that in other cases that such a delay could result in the unnecessary premature death of a atient which is wh YOUR RESPONSE this concern. I am raisin You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 August 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person, 1111 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. 6 . 7. 8. Dated 25 June 2020 Si natur~ ~die , Senior Coroner for Wiltshire & Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP Tel 01722 438900 I Fax 01722 332223
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.
Great Western Hospitals h'J:kj NHS Foundation Trust The Great Western Hospital Marlborough Road Swindon SN36BB Tel: 01793 60 40 20 Private and confidential David Ridley HM Senior Coroner for Wiltshire and Swindon Wiltshire and Swindon Coroner's Office 26 Endless Street Salisbury Wiltshire SP11DP By email only: 26 August 2020 Dear Mr Ridley Re: Coroner's Regulation 28 Report Thank you for your letter dated 25 June 2020, which included a Regulation 28 Prevention of Future Deaths Report, raising concerns about the circumstances which led to the death of Mrs Winifred Mary Redfearn. We take these reports extremely seriously and I am writing to share our response to your report, which aims to provide assurance that your concerns have been addressed and includes details of the actions taken or planned to reduce the risk of similar deaths. As an organisation, we have also conducted our own internal investigation into the care provided to Mrs Redfearn, which will be shared with you once it has been through our governance process, this is scheduled to be completed by October 2020. This investigation identified a number of areas where improvements are needed to ensure all patients receive safe and high quality care Details of action taken or action planned, in response to the matters· giving rise to concern within your report and our own internal investigation, are outlined below. Overview There was a delay of two and half days, which included a weekend, in resuming Mrs Redfearn's medication 'Dalteparin' (an anticoagulant that helps prevent the formation of blood clots), after it was suspended pending the result of a CT scan. Our Values Service Teamwork Ambition Respect 1 You have acknowledged that there is no evidence to suggest that this omission caused or contributed to Mrs Redfearn's death, however believe that there is a risk of similar incidents occurring, posing a potential risk to other patients. This has led to your concern about treatment being delayed, and the safety and quality of care given to · patients potentially being of a different standard during weekends. The Trust has therefore taken the following actions. Matters of concern and actions taken Raising awareness vye know that openly recognising mistakes leads to improved patient safety and we encourage staff to speak up so we can learn and make improvements. Action Mrs Redfeam's case has been discussed internally within the speciality, supporting our culture of openness and transparency. Openly discussing where omissions. in care were identified will raise awareness of potential risks to patient safety, actions we need to take to reduce these risks and ultimately inform changes which will lead to improved patient care. IT based system for weekend review of patients It was identified that there is no robust system for medical reviews of patients during weekends. Currently, patients who require medical review over the weekend are added to a paper handover, which ·is not shared between wards. This system contributed to Mrs Redfearn not being reviewed by a doctor over the weekend. Action By mid-September a new electronic review system will be available at weekends. This will clearly identify which treatment is required, and which doctor and speciality the patient has been allocated. Importantly, the information will be accessible from any location for review during weekends. The information will also be retained. Our Values Service Teamwork Ambition Respect 2 Venous Thromboembolism (VTE) There are two areas of improvement to be made around VTE care. 1) The VTE risk assessment is completed on an electronic prescribing system called EPMA, while nursing handover information is stored on a different electronic system called Nervecentre. The fact that Mrs Redfearn's medication was suspended pending the result of a CT scan, was not documented on either system. Had this been documented, it may have acted as a prompt fo~ nursing staff to escalate this information to medical staff. 2) Ward staff lacked sufficient knowledge regarding the increased risk of VTE from not having Dalteparin, alongside the patient's immobility and not wearing electronic regular compression boots. Had the ward staff been aware of the importance of Dalteparin, the absence of this medication may have been escalated. Action A training plan is being developed to raise awareness of the importance of methods to mitigate the risk of VTE and the importance of clear documentation. The training will commence in September 2020. The admission of patients to the appropriate speciality The Trust's current criteria is that any patient over the age of 65, admitted with a trauma, should be placed under the care of the trauma and orthopaedic speciality, with further input where required. Mrs Redfearn was admitted from the Emergency Department (ED), to a medical ward called the Treatment for Older Persons Short Stay Unit (TOPSSU). Had Mrs Redfearn been under the care of the trauma and orthopaedic speciality, they would have been more aware of the necessity for review of patients after CT scanning and the need for VTE prophylaxis. Mrs Redfearn was on TOPSSU when her spinal fracture was diagnosed. This should have triggered a referral to the Spinal Team via the Oxford Acute Referral System (OARS), which enables the spinal team to review CT images and advise on treatment. There was a delay in this happening. Action In August 2020, the criteria regarding patients over the age of 65, admitted with a trauma, having care delivered by the trauma and orthopaedic speciality was shared widely throughout the unscheduled care and planned care divisions to increase awareness. The criteria will also be displayed in all patient Our Values Service Teamwork Ambition Respect 3 admission areas of the hospital. An audit will be undertaken in September to ensure that there is compliance with the criteria. The protocol for referrals to the Spinal Team via OARS will also be reviewed. The Trauma and Orthopaedic clinical lead/spinal consultant will be leading the OAR review and will be working with OUH. This is expected to take at least 3 months. Trauma alerts Pre-alerts are made by the ambulance service and enable the Trauma Team to be called prior to the patient arriving, and the relevant specialties to be involved from the time the patient arrives in ED. Silver trauma is a 'way of acknowledging that older people are at a higher risk of significant injury with lower impact mechanisms of injury. In circumstances where the ambulance service has not made a pre- alert call, ED staff can raise this alert. · · During Mrs Redfearn's care this process was not followed. This meant that the Orthopaedic Team was not Involved at the earliest opportunity and that imaging could have been done sooner in ED. Action Further training will be provided to staff to increase their knowledge of pre-alert calls for silver trauma cases. Training will be provided to ED nursing and medical groups by 30 September 2020. The training will be provided by the ED clinical nurse educator and senior medical staff. The case will also be highlighted to the ambulance service so that they can ensure training is delivered to their staff. I hope that _this letter provides you with assurance that action has been taken in response to your report and that further actions are planned to address the concerns raised and improve the standard of care patients receive. If you require any further information, please do not hesitate to contact me. Yours sincerely Chief Executive . Copy to: CQC Our Values Service Teamwork Ambition Respect 4
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