Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0220, written 29 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Oct 2020 |
|---|---|
| Reference | 2020-0220 |
| Deceased | Sarah Gibbs |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Emergency Services 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: Chief Executive Officer Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY 1. CORONER I am Jacqueline LAKE, Senior 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 Aspiration of Gastric Contents Vomiting On 25/04/2019 I commenced an investigation into the death of Sarah Nadine Louise GIBBS aged 38. The investigation concluded at the end of the inquest on 26/10/2020. The medical cause of death was: 1a) 1b) 1c) 1d) 2 Acute Peritonitis Following Recent Insertion of PEG tube to Assist Nutrition (in patient with learning disabilities and epilepsy) The conclusion of the inquest was: Sarah Gibbs died shortly after returning home following a medical procedure. 4. CIRCUMSTANCES OF THE DEATH Sarah Gibbs had learning disabilities, lacked mental capacity and had difficulty feeding. She underwent a PEG operation on 16 April 2019. Sarah was discharged home on 17 April 2019. The result of an earlier blood test was not known and she was not seen by a Doctor immediately prior to discharge. Later that day, Sarah became unresponsive and emergency services were called. A defibrillator was not able to be accessed. Sarah was pronounced dead at the scene. 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: Concerns were raised during the inquest with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over. Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood for errors in communication information. It was not known whether this tool is in use although it was “hoped” it is being used. This is some eighteen months following Miss Gibbs’s death. 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 24 December 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: Mr and Mrs Gibbs, (Parents) I have also sent it to: Department of Health Care Quality Commission HSIB Healthwatch Norfolk 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: 29 October 2020 Jacqueline LAKE Senior 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.
. Our Vision 0 To provide every patient with the care we want for those we love the most Norfolk and Norwich university Hospitals [I] NHS Foundation Trust Office of the Chief Executive Norfolk & Norwich University Hospitals NHS Foundation Trust Norwich Research Park Colney Lane Norwich NR4 ?UY Private & Confidential Mrs Jacqueline Lake Senior Coroner Norfolk Coroner's Service County Hall Martineau Lane Norwich NR1 2DH 14 December 2022 Dear Mrs Lake Sarah Nadine Louise GIBBS I write to formally respond to the Regulation 28: Report to Prevent Future Deaths I apologise on behalf of the Trust for issued following this inquest in October 2020. (Trust the delay: no disrespect was intended. Solicitor) has already written to your team to explain how this occurred. It is now my intention to provide you with the information that was originally collated and to update you with regards to the position now. I understand that During the inquest, a concern was raised "with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over. Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood for errors in communication information. It was not known whether this tool is in use although it was "hoped" it is being used." December 2020 SBARD is a structured form of communication that consists of standardised prompt questions in four sections: S (Situation); 8 (Background); A (Assessment) and R (Recommendation). It can also include a final section, D (Decision). As at December 2020, staff were encouraged and trained to use SBARD as a In some areas, there were posters communication method across the hospital. displaying how the tool benefits communication and what the tool is with the steps clearly laid out. These were first issued by the Critical Care Outreach Team. SBARD was consistently used for the presentation of cases to SIG and providing information in response to enquiries for the CQC. There was not the evidence available to provide assurance that this communication tool was in consistent and regular use with patient facing teams for escalating concerns. The Trust was also planning to undertake a large scale digital improvement project to implement eObs and a clinical messaging system to improve the escalation of deteriorating patients to response teams. In addition, we were planning to expand the Recognise and Respond team with their remit to include training and education. December 2022 SBARD is integrated into the patient handover used by the wards at every handover. There is a template document used with each section of the SBAR tool to be completed by staff. This has been in place at the Trust for approximately 18 months. EObs has been introduced at the Trust. Since June 2021, the Recognise and Response Team (RRT) has been expanded to provide their services 24/7. The RRT works across inpatient wards responding to acutely deteriorating patients, attending resuscitation calls in the hospital as well as delivering education, training and quality improvement projects. The RRT lead in the education and training of Trust staff in the assessment and management of acutely unwell patients, providing basic, intermediate and advanced resuscitation courses and bespoke acute deteriorating patient courses for medical students, doctors, nurses, midwives and HCAs. The RRT teach SBARD on all new staff inductions; Assess, Communicate, Treat Courses; ALERT course; HCA study day; and BEACH course, as well as ad hoc ward training. The t eam are about to launch a new NEWS2 e-learning course which also teaches SBARD. I hope the information provided within this letter reassures you about the steps taken to implement SBARD into our processes and to improve communication between teams. Yours sincerely Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.