Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0191, written 30 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Sep 2020 |
|---|---|
| Reference | 2020-0191 |
| Deceased | Mavis Lawrence |
| Coroner | Margaret Jones |
| Coroner area | Stoke-on-Trent & North Staffordshire Coroner’s Court |
| Category | Care Home Health related deaths · Community health care |
| Organisation named | Midlands Partnership University 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 THIS REPORT IS BEING SENT TO: Midlands Partnership NHS Foundation Trust (District Nursing team) Beechdene Residential Home Leek Health Centre (GP) CORONER 1 I am Margaret Joy Jones Assistant Coroner for Stoke-on-Trent & North Staffordshire Coroner's Court 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.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 28/05/2020 I commenced an investigation into the death of Mavis May Lawrence. The investigation concluded at the end of the inquest 30th September 2020. The conclusion of the inquest was:- “The deceased died from natural causes exacerbated by infected pressure sores.” The deceased was 87 years of age and suffered with severe dementia. She required full nursing care. She had been resident at Beechdene Residential Home, Leek since September 2018. She had been seen regularly by District Nursing teams to assess and treat her pressure areas but tissue viability nurses were not involved. Preventative measures including pressure relieving equipment were in place; however nursing notes evidenced gaps in pressure care between 3rd December 2018 and the 27th January 2019 when she was admitted to the Royal Stoke University Hospital, Stoke-on-Trent. She was dehydrated and found to have deep ungradable pressure sores and an abscess on her buttock. She was discharged to Goldenhill Nursing Home, Heathside Lane, Stoke on Trent on the 13th February 2019 for end of life care where she died on the 28th February 2019. The cause of death was given as:- 1a. Bronchopneumonia. 1b. Immobility. 1c. Alzheimer’s dementia. 2. Old age and infected pressure ulcers. 4 5 CIRCUMSTANCES OF THE DEATH See above - 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 matters that are raised in the safeguarding report:- (1)Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes. (2)No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas. (3)Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers. (4) The pressure mattress had been turned off on the 22.1.19 (5)No record of last visit by district nurses on the 27.1.19 (6) There was no evidence that band 4 nurse escalated the seriousness of the situation. (7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. . (8) District nurses had not involved Tissue Viability Nurses. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you the Midlands Partnership NHS Foundation Trust; Beechdene Residential Home and Leek Health Centre (GP) 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 27th November 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely to the family and to the Local Adult Safeguarding Board. 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 30/09/2020 Signature: Margaret J Jones, HM Assistant Coroner Stoke-on-Trent & North Staffordshire Coroner's Court
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.
Ms M A Jones Her Majesty’s Assistant Coroner Stoke-on-Trent & North Staffordshire Coroner`s Office Stoke Town Hall Kingsway Stoke-on-Trent ST4 1HH 25th November 2020 Dear Ms Jones Re: Mavis May Lawrence (deceased) Report to prevent Future Deaths Thank you for your letter dated 1st October 2020, reporting matters to us, in accordance with Regulation 28 and 29 of the Coroner’s (Investigations) Regulations 2013. Following discussions within the teams involved, I am now in a position to respond to your specific concerns, whereby you stated you heard at the inquest during the course of the evidence: I am sorry that a complete set of records was not made available to you at the point of the inquest. We note, as part of your inquest conclusion and subsequent concerns outlined in your Regulation 28 report, that unfortunately you did not have access to the My Care File, which contains the records held at a patient’s home or place of residence. Our response is made on the basis of our review of the relevant MPFT care records. We have responded to each of the concerns raised and identified some actions, which are in the action plan below for your information. (1) Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes. We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c). (2) No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas. There is evidence in the deceased’s records that wound assessments were undertaken after the 18.12.2018. Wound assessments were completed on the 01.01.2019 and on the 27.01.2019 clearly documenting the condition and anatomical location of the wounds. The MPFT guidance is that wound assessments need to be carried out and documented on a fortnightly basis. If the wounds deteriorate before the next fortnightly review, a wound assessment will be completed prior to that date. Records show that in between the regular wound assessments there were regular summaries of the condition of the wounds. Up until the date of admission to hospital the records 1 state that the wounds to the sacral and right hip area were improving, granulating (healing) or that there were no concerns to raise. The assistant practitioner (band 4 nurse from the district nursing team) has documented that there may be a new non blanching area to the right hip. The assistant practitioner (band 4 nurse from the district nursing team) recorded in the nursing notes that “the family has been advised of Mavis’s presentation and requirements” on the last wound assessment on the 27.01.2019. (3) Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers. Please see response above. (4) The pressure mattress had been turned off on the 22.1.19 The Residential Home is responsible for ensuring appropriate use of the equipment. Our records show that during a routine visit on 22.1.19 the district nurse noticed that the pressure mattress had been turned off, and took immediate action and turned it back on. (5) No record of last visit by district nurses on the 27.1.19 When the patient is cared for in a residential home, the carers are expected to carry out regular skin checks as they are tending to the patient, on a regular basis. The process in place requires that the care staff raise concerns to the district nurses as and when required. There is evidence in the care records that MPFT staff did request the Residential Home staff contact MPFT district nursing staff if they had any concerns. There is evidence of a wound assessment table having been completed by the assistant practitioner (band 4 nurse from the district nursing team) on 27.1.19, in the My Care File when the assistant practitioner (band 4 nurse from the district nursing team) was requested by the Residential home care staff to complete an assessment. (6) There was no evidence that band 4 nurse escalated the seriousness of the situation. There is evidence in the records that the band 4 nurse escalated this appropriately and notified the nurse in charge of the district nurse team, as well as the tissue viability team, on Sunday 27th January 2019. (7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.) (8) District nurses had not involved Tissue Viability Nurses. The district nurses and assistant practitioner band 4 assistant practitioners are skilled in managing wounds; including pressure ulcers. The wounds were documented to be healing prior to the 27th January 2019. The assistant practitioner (band 4 nurse from the district nursing team) was at the Residential Home reviewing other patients when the Residential Home staff requested an assessment be completed by her on that day. In line with our Trust policy for pressure ulcer prevention and management, the practice is that the district nurses will refer to the tissue viability team when there is deterioration in a wound. Once the assistant practitioner (band 4 nurse from the district nursing team) identified (on assessment) that the wounds were deteriorating they followed the correct process of incident reporting, and notified 2 the nurse in charge of the district nurse team, as well as the tissue viability team, on Sunday 27th January 2019. MPFT has identified the following actions to improve processes. Action Lead Leek District nursing Team Completion Date 31.01.2021 Operational Lead for Leek district nursing team Operational Leads Professional Lead & Tissue Viability Lead 30.11.2020 Check audit and compile report for senior management Clinical Lead & District Nursing Commenced by 30.11.2020 31.10.2020 Professional Lead for Community Nursing Tissue Viability Clinical Lead Professional Lead for Community Point 1 – 1.Provision of additional training in wound care documentation utilising the YouTube training link developed by MPFT Tissue Viability Team (Wound assessment training) Point 1 – 2.An audit of nursing documentation including pressure ulcer management Point 7 – 3.To raise awareness of the need to involve the GP in the ongoing management of patient care as part of the multidisciplinary team Point 7 – 4a. Documentation will be improved. The pain assessment tool has been reviewed and updated; a relaunch with all clinical staff took place in August 2020. 4b. The patient care plan template to be updated to incorporate the pain assessment tool. District nursing teams and Home First Teams Trust Wide Completion Date Each operational lead to check training register and to ensure all staff have undertaken the update training Develop an audit tool for all community/district nursing teams and a pressure ulcer audit will take place Trust wide To raise awareness of the need to involve the GP in the ongoing management of patient care as part of the multidisciplinary team The audit tool will identify if this process has been embedded 31.01.2021 28.02.2021 Commenced by 30.11.2020 31.10.2020 31.12.2020 28.02.2021 3 4c. An audit will take place to ensure the pain assessment process is embedded in clinical practice Point 1 & Point 7 5. A new Community Nursing Assessment document has been introduced to document a holistic assessment for patients referred into the District Nursing service to identify needs based on the activities of daily living model. 6. Multidisciplinary team to share best practice and learning from incidents across all clinical teams via a monthly newsletter following each Pressure Ulcer Review Group and Tissue Viability Steering Group meeting for discussion at team huddles Nursing Tissue Viability Clinical Lead Completed 04.11.2020 Tissue Viability Clinical Lead 04.11.2020 Multidisciplinary team sharing best practice and learning from incidents Across all clinical teams A monthly newsletter following each Pressure Ulcer Review Group and Tissue Viability Steering Group meeting In line with our governance processes we will share the learning from the Regulation 28 and the actions identified will be monitored, to ensure the action plan is fully completed. I hope this response helps to address your concerns. However if you require any further information please do not hesitate to contact me. Yours sincerely Chief Executive 4
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