Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0149, written 4 Aug 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 Aug 2020 |
|---|---|
| Reference | 2020-0149 |
| Deceased | Pauline Russell |
| Coroner | Yvonne Blake |
| Coroner area | Norfolk |
| Category | Alcohol, drug and medication related deaths · 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS . REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO The Chief Executive James Paget University Hospital Lowestoft Road Great Yarmouth Norfolk NR31 6LA 1 CORONER I am Yvonne BLAKE, Area Coroner for the area of Norfolk 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 25 November 2019 I commenced an investigation into the death of Pauline Russell aged 61. The investigation concluded at the end of the inquest on 31/07/2020. The conclusion of the inquest was a narrative conclusion as follows: Mrs Pauline Russell died at the James Paget Hospital, Lowestoft Road, Gorleston, Norfolk on 22 November 2019 from Aspiration Pneumonia following her collapsing in a hypoglycemic coma. Mrs Russell had been injecting a higher incorrect dose of insulin since her discharge from hospital on 11 November 2019. The Medical Cause of Death is 1a Aspiration Pneumonia 1b Hypoglycaemic Coma 2. Insulin Dependent Diabetes Mellitis, Previous stroke. 1 CIRCUMSTANCES OF THE DEATH Mrs Russell, a poorly controlled diabetic, was admitted to the James Paget Hospital, Gorleston, Gt. Yarmouth on 6/11/19 with a history of falls, and a urinary tract infection. She took amongst other things, insulin twice daily. Her insulin was increased to 64 units twice daily and she was discharged on 8/11/19 on this regime. Neither or Mrs Russell can read or write. Mrs Russell went home first, and her husband returned to the hospital to collect her medication. He was given a bag of medication and saw a letter inside. The staff nurse gave evidence that he went through Mrs Russell’s medications with using the discharge letter as reference. In any event Mrs Russell told her husband when he returned home that the doctor had increased her insulin to 92 units twice daily. told. The correct dose to be given was listed on the discharge summary which neither could read. Mrs Russell received 5 days of 92 units of insulin B.D. drew it up in the pen because Mrs Russell had cataracts and she injected it herself. On the morning of the 17/11/19 a carer arrived, and Mrs Russell was unresponsive and so she began resuscitation and called an ambulance. Mrs Russell was given glucose by paramedics which slightly improved her condition, but she did not wake up. Life support was withdrawn, and Mrs Russell died on 22/11/19. 2 CORONER’S CONCERNS queried this, but she was adamant that is what she had been The MATTERS OF CONCERNS are as follows: That no-one checked whether Mrs Russell could read, her admission pack has a long section on communication but not once is the question asked can you read/write or something of that nature. Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this. On discharge no one checked that could read and understand the discharge summary. The inquest was 8 months after Mrs Russells’ death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice. The hospital has not introduced anything during this long period of time to ascertain if their patients can read/write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are, eg. a diagram, getting a relative to read them or a carer. I find it surprising that nothing has been done on the hospital’s own initiative in 8 months and I remain concerned that a similar incident may occur again. 3 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 4 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 September 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. 5 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (Spouse) I have also sent it to: Department of Health Care Quality Commission Healthwatch Norfolk HSIB, who may find it useful or of interest. 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. Dated: 04 August 2020 Yvonne BLAKE Area Coroner for Norfolk Norfolk Coroner Service Carrow House 301 King Street Norwich NR1 2TN
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.
2- 4 SEP 2020 Ms Yvonne Blake Area Coroner for Norfolk Carrow House 301 King Street Norwich NR1 2TN 21 September 2020 Dear Ms Blake ,,,1:k1 James Paget University Hospitals NHS Foundation Trust Lowestoft Road Gorleston Great Yarmouth Norfolk NR31 6LA Main Switchboard: 01493 452452 Direct D ia l :_ Direct Fax: E mail: complaints@jpaget.nhs.uk www.jpaget.nhs.uk Re: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mrs Pauline Russell. Thank you for your letter received on 10 August 2020 following your inquest into the death of Pauline Russell. Firstly, I would like · to offer my condolences on behalf of the Trust to Pauline's family for her sad passing. Following the evidence heard at your inquest, the medical cause of death was given as: 1 a) Aspiration Pneumonia 1 b) Hypoglycaemic Coma 1c) - 2) · Insulin Dependent Diabetes Mellitis, Previous Stroke I understand that you have made 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. The Trust has carefully considered the issues set out in your letter in order to respond to your concerns. Following your inquest, the hospital's Director of Nursing instigated a review of the admission and discharge documentation used across the Trust to identify any required changes. As a result of this review, the admission and discharge documentation has been amended to include additional checks relating to literacy support. The Multi-Disciplinary Care Recorc:rh-ow requires staff to check whether the patient is able to read English and if any additional support is required. The 'Discharge Checklist' also highlights language and literacy skills to the completing staff and signposts them to the new admissions booklet. Please see enclosed copy of the amended documentation. The updated documentatior:, has been shared with. ward managers to cascade accordingly and the documentation will be formally launched at the Clinical Leaders Event on 7 October 2020. To ensure compliance, the Trust will carry out a monthly audit of this documentation with the first results available at the end of October. During the discharge proce~s, nursing staff are expected to discuss medications With patients and their relatives (if appropriate) to ensure that they have a full understanding of their medication administration. This discussion should include specific information about the dosage to avoid any misinterpretation. If concerns are identified during the medicines reconciliation process, this would be assessed and the patient and their carers. supported accordingly. Staff are encouraged to use a 'Check and Challenge' approach to ensure patients have a full and safe understanding of their medications. This approach includes staff asking questions to patients and carers to evaluate their understanding and identify if further assistance is required, for example an interpreter. In March 2020, the pharmacy department implemented a new system which communicates a patient's _discharge letter to· their usual community pharmacy: this allows a further opportunity to offer medication support. In addition, the discharge letter is sent to the patient's General Practitioner to arrange any require~ follow up and make them aware of any medication changes. I understand in this case, nursing staff were unaware of the patient's and carer's literacy difficulties and I am satisfied that the cha,nges to documentation and learning from this case will help prevent a similar inciqent occurring. I would like to thank you for bringing your concerns to my attention. If you require anything further, then please do not hesitate to contact me. I understand that this letter may be shared with Paulina's family and I would like to take this opportunity to personally extend my sincere condolences for their loss. Yours sincerely B ! ! t i v e
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