Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0223, written 5 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Nov 2020 |
|---|---|
| Reference | 2020-0223 |
| Deceased | Ann Smith |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Princess Alexandra Hospital 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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 13 September 2019 I commenced an investigation into the death of Ann Margaret Smith. The investigation concluded at the end of the inquest on 3 November 2020. The conclusion of the inquest was that she died as a result of an accident contributed to by natural disease. The cause of death was 1a) subdural and intracerebral haemorrhage 11) Hypertensive Heart Disease and Bronchopneumonia CIRCUMSTANCES OF THE DEATH The deceased was admitted to Princess Alexandra Hospital on 8 September 2019 and on 9 September she suffered an unwitnessed fall. She sustained a head injury and she died on 13 September 2019 CORONER’S CONCERNS 4 5 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. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is the lack of a local protocol (part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and being given treatment dose of clexane for another clinical reason eg suspected pulmonary embolus, who sustain head trauma. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 1 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 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 – The family 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 5 November 2020 Caroline Beasley-Murray senior coroner Essex 2
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.
Hamstel Road
Harlow
Essex
CM20 1QX
26th August 2021
To Senior Coroner Lincoln Brookes
Chelmsford Coroner’s Court
Dear Coroner Brookes,
Re: Ann Margaret Smith (Deceased)
I am writing to you in my role of Medical Director at The Princess Alexandra Hospital NHS
Trust (PAHT) regarding the inquest into the death of Mrs Ann Smith.
This inquest was heard before Senior Coroner Beasley-Murray on 3rd November 2020. In
conjunction with her conclusion, Ms Beasley-Murray issued a Regulation 28 report to which
PAHT responded on 30th December 2020. Part of that response promised a subsequent
update would be provided to the Senior Coroner by March 2021. I have now established that
this update was unfortunately not forthcoming, primarily as a result of the overwhelming
priorities of the Covid wave. Please accept my sincere apologies for this oversight.
Ms Smith was admitted to Princess Alexandra Hospital on 8th September 2019. The
following day she suffered an unwitnessed fall which resulted in a head injury and she sadly
died on 13th September 2019.
Senior Coroner Beasley-Murray indicated in her Regulation 28 report that she was
concerned that ‘there was uncertainty in how to deal with the anti-coagulation aspect of Ms
Smith’s care in the wake of her fall. That there was a lack of a local protocol for the
management of the sub-group of patients over 65, on anticoagulants, and being given a
treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus,
who then sustain a head trauma’.
The importance of the patient having a clearly identified anticoagulation action plan post fall
remains a priority for PAHT. The Action Plan developed by our multi-disciplinary
Anticoagulation/Falls Tasking Group continues apace and I include with this letter the
previously promised update of progress with that.
PAHT remains committed to ensuring that all of our clinical, nursing and allied health
professional staff are fully conversant in falls prevention and falls management. Our
Strategic Falls Prevention Plan for 2021/22 is focussed on continued training and oversight
to ensure preventative actions.
We continue to make progress with regards to overall patient falls with harm, and I am
pleased to say that we have achieved a 10% reduction during quarter 4 of 2019-20, and also
in each of quarters 1 & 2 of 2021. Our goal is to reduce the number by 50% by the end of
March 2022.
I remain confident that the Trust is on course to deliver the necessary changes required.
Yours sincerely
Medical Director
Overall Aim - To address the Regulation 28 noticed served by HM Coroner for Essex (November 2020)
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. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is the lack of a local protocol
(part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and being given treatment dose of clexane for another
clinical reason e.g. suspected pulmonary embolus, who sustain head trauma.
Goal
Actions
Establish a task and finish group comprising:
Associate Medical Director for the Medicine
Healthcare group.
Anticoagulation pharmacist.
Lead Nurse for Falls Prevention
1. To establish
a task and
finish group to
review the
current
protocols and
make
necessary
changes
By
When
Nov-
20
By Whom
Progress
Measures of success
RAG
Lead Nurse
for Falls
Prevention
Group has been established Group has been established
Review of the falls prevention policy
Feb-
21
Task and
finish group
2. To review
the current falls
prevention
policy and to
provide an
update to
include the
management
of this sub
group of
patients. This
will include the
quick reference
guides on post
falls
management
that are
included in the
appendices of
the policy
Fully updated falls prevention
policy and quick reference
guides available in all clinical
areas. The policy and quick
reference guides will be fully
updated by the end of
January 2021for submission
to the Patient Safety Group
meeting and Trust policy
group meeting in February
2021
The policy and quick
reference guides have been
reviewed. There needs to a
section added to the policy
relating to this sub-group of
patients with regard to:
anticoagulation plan - post
fall to STOP or CONTINUE
anticoagulation therapy.
Frequency and duration of
observations, including
neuro-observations. Update
March 21. Updated policy
and quick reference guides
have been distributed to all
in-patient areas. These have
been shared widely with ward
teams, matrons, HoNs
ADoNs, AHP staff, junior
medical staff and
consultants. Information is to
be shared at ward huddles,
handovers, ward meetings,
PS&Q meetings. Changes
have been approved by the
Clinical Cell and Trust policy
group. Changes to be
included on junior doctor
anticoagulation training and
will be added to the Trust
anticoagulation guidelines.
Internal safety bulletin has
been issued. E mail sent to
all junior doctors and all
consultants.
Task and
finish group
3. For each
patient in this
sub-group to
have a clearly
documented
Anticoagulation
plan.
Feb-
21
To ensure that this sub-group of patients has a clearly
identified anticoagulation action plan post fall. A
medical decision needs to be made regarding STOP
or CONTINUE anticoagulation therapy post fall and
this must be clearly documented in the patient's
clinical record. If the anticoagulation therapy is to be
stopped then the prescription MUST be suspended on
the EPMA system. This will need to be formally
agreed by the Senior Management Team.
Senior Practitioners Forum.
Clinical Cell.
This policy will be added to all anticoagulation
guidelines
Fully updated falls prevention
policy and quick reference
guides available in all clinical
areas. ALL clinical staff to be
made aware that this is a
mandatory requirement. This
will be achieved by training
and also the issuing of an
Internal Safety Bulletin (March
2021) etc. For this policy to be
added to all anticoagulation
guidelines
The policy and quick
reference guides have been
reviewed. There needs to a
section added to the policy
relating to this sub-group of
patients with regard to:
anticoagulation plan - post
fall to STOP or CONTINUE
anticoagulation therapy.
This action was approved at
the Clinical Cell meeting
December 2020.
This is to be formally
discussed at the
anticoagulation meeting in
January 2021.
The Haematology teams
have been asked to provide
formal feedback on this
change to the policy.
25.01.21 - Feedback has
been received and added to
revised policy. Update March
21 - see above (section 2)
4a. For the
timing,
frequency and
completion of
observations
(including
neurological
observations)
to be
mandatory
The timing and frequency of observations (including
neurological observations) is currently clearly
identified on the post fall quick reference guides. This
requirement needs to be clearly referenced on all
clinical staff training sessions (see point 5 below). In
addition to formal training sessions this change to
practice will be shared with the Patient Safety and
Quality Leads for dissemination across the healthcare
groups with the expectation that it will also be
discussed at patient safety huddles on a daily basis
(for 2 weeks) and then weekly (for 4 weeks
commencing in January 2021
Feb-
21
Task and
finish group
The policy and quick
reference guides have been
reviewed
Fully updated falls prevention
policy and quick reference
guides available in all clinical
areas. ALL clinical staff to be
made aware that this is a
mandatory requirement. This
will be achieved by training
and also the issuing of an
Internal Safety Bulletin.
Issued March 2021
Nerve Centre needs to be amended to ensure that the
completion of all sections of neurological observations
are mandatory
Jan-
21
Lead for
Clinical
Information
systems
The update to Nerve Centre
has been agreed. The aim is
for this to be "live" week
commencing 18th January
2021
Update to Nerve Centre.
25.01.21 This amendment
has now been completed and
has been communicated to all
ward managers and matrons
4b. For an
update to be
made to Nerve
Centre to
ensure that
completion of
all parts of
neurological
observations
are mandatory
5. For all of the
above actions
to be included
in mandatory
falls prevention
and
management
training for all
clinical staff
6. Mandatory
question to be
added to the
Datix incident
management
system as to
whether patient
who has fallen
is on
anticoagulant
therapy
7. Trust
strategic
Quality
Improvement
Plan
8. Corporate
risk register
Falls training to be made mandatory for all clinical
staff and for the above actions to be part of this
training. This policy is also to be added to the training
provided by the anticoagulation pharmacists.
Feb-
21
For clinical staff to be up to
date with mandatory falls
prevention and management
training
Lead Nurse
for Falls
Prevention
The process to make falls
prevention and management
training mandatory for all
clinical staff has begun. All
training packages (face to
face and e learning) will be
amended to include the
above actions). Current face
to face sessions provided by
the Lead Nurse for Falls
Prevention includes
discussion on anticoagulation
and the requirement for the
completion of neurological
observations
Datix to be amended to include this question
Feb-
21
Lead Nurse
for Falls
Prevention
02.02.21 Mandatory question
now added to Datix .
Complete
Action to be formally added to the Trust's Strategic
Quality Improvement Programme
Feb-
21
Now formally added to QIP
Complete
Associate
Director for
Quality
Governance
Risk to be added to Corporate Risk Register
Feb-
21
Lead Nurse
for Falls
Prevention
Formal risk assessment has
been completed. Pending
approval from Deputy
Director of Nursing. Once
approved - will be added to
Corporate Nursing Risk
Register until corporate risk
register is established
Complete
Private and Confidential
Senior Coroner Caroline Beasley-Murray
Essex Coroner’s Court
Chelmsford County Hall
Victoria Road
Chelmsford
CM1 1QH
Dear Coroner Beasley-Murray,
30th December 2020
I write in the matter of the late Ann Smith in response to your recent Regulation 28 Report to
prevent future deaths.
Ms Smith was admitted to Princess Alexandra Hospital on 8 th September 2019. On 9th
September she suffered an unwitnessed fall which resulted in a head injury. She sadly died
on 13th September 2019 and your inquest into her death was held on 3rd November 2020.
You were concerned that ‘there was uncertainty in how to deal with the anti-coagulation
aspect of Ms Smith’s care in the wake of her fall. That there was a lack of a local protocol for
the management of the sub-group of patients over 65, on anticoagulants, and being given a
treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus,
who then sustain a head trauma’.
The speed at which action is taken following a fall is clearly significant, as is the importance
of the patient having a clearly identified anticoagulation action plan post fall. To that end, the
Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group comprising of
the Associate Medical Director for the Medicine Healthcare group, the Anticoagulation
Pharmacist and the Lead Nurse for Falls Prevention.
This group has developed an Action Plan, a copy of which I share with you. Whilst the
actions from this plan are still ongoing, I am confident that the Trust is on course to deliver
the necessary changes to ensure that there are no further severe harms or deaths from thi s
type of incident. I propose to update you again by the end of March 2021.
Yours sincerely
Director of Nursing, Midwifery & Allied Health Professionals
Action Plan
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. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is
the lack of a local protocol (part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and
being given treatment dose of clexane for another clinical reason e.g. suspected pulmonary embolus, who sustain head trauma.
Goal
Actions
By Whom
Progress
Lead Nurse
for Falls
Prevention
Group has been
established
Measures of
success
Group has been
established
Status
Complete
By
When
Nov-20
Establish a task group
comprising: Associate
Medical Director for
the Medicine
Healthcare group.
Anticoagulation
pharmacist.
Lead Nurse for Falls
Prevention
1. To establish a
task group to
review the current
protocols and
make necessary
changes
2. To review the
current falls
prevention policy
and to provide an
update to include
the management
of this sub group
of patients. This
will include the
quick reference
guides on post falls
management that
are included in the
appendices of the
policy
Review of the falls
prevention policy
Dec-20
Task group
On-going
Fully updated falls
prevention policy
and updated and
updated quick
reference guides
updated and
available in all
clinical areas. The
policy and quick
reference guides
will be fully
updated by the
end of January
2021for
submission to the
Patient Safety
Group meeting
The policy and
quick reference
guides have been
reviewed. There
needs to a section
added to the
policy relating to
this sub-group of
patients with
regard to:
anticoagulation
plan - post fall to
STOP or
CONTINUE
anticoagulation
therapy.
Frequency and
duration of
observations,
including neuro-
observations.
3. For each patient
in this sub-group
to have a clearly
documented
Anticoagulation
plan.
4a. For the timing,
frequency and
completion of
observations
(including
neurological
observations) to
be mandatory
Task group
Jan-21
To ensure that this
sub-group of patients
has a clearly identified
anticoagulation action
plan post fall. A
medical decision
needs to be made
regarding STOP or
CONTINUE
anticoagulation
therapy post fall and
this must be clearly
documented in the
patient's clinical
record. If the
anticoagulation
therapy is to be
stopped then the
prescription MUST be
suspended on the
EPMA system. This
will need to be
formally agreed by the
Senior Management
Team.
Senior Practitioners
Forum.
Clinical Cell.
This policy will be
added to all
anticoagulation
guidelines
On-going
Fully updated falls
prevention policy
and updated and
updated quick
reference guides
updated and
available in all
clinical areas. ALL
clinical staff to be
made aware that
this is a mandatory
requirement. This
will be achieved
by training and
also the issuing of
an Internal Safety
Bulletin. For
this policy to be
added to all
anticoagulation
guidelines
The policy and
quick reference
guides have been
reviewed. There
needs to a section
added to the
policy relating to
this sub-group of
patients with
regard to:
anticoagulation
plan - post fall to
STOP or
CONTINUE
anticoagulation
therapy.
This action was
approved at the
Clinical Cell
meeting December
2020.
This is to be
formally discussed
at the
anticoagulation
meeting in January
2021.
The Haematology
teams have been
asked to provide
formal feedback
on this change to
the policy.
Task group The policy and
quick reference
guides have been
reviewed
On-going
Fully updated falls
prevention policy
and updated and
updated quick
reference guides
updated and
available in all
clinical areas. ALL
clinical staff to be
made aware that
this is a mandatory
requirement. This
will be achieved
by training and
also the issuing of
an Internal Safety
Bulletin.
Jan-21
The timing and
frequency of
observations
(including neurological
observations) is
currently clearly
identified on the post
fall quick reference
guides. This
requirement needs to
be clearly referenced
on all clinical staff
training sessions (see
point 5 below). In
addition to formal
training sessions this
change to practice will
be shared with the
Patient Safety and
Quality Leads for
dissemination across
the healthcare groups
with the expectation
that it will also be
discussed at patient
safety huddles on a
daily basis (for 2
weeks) and then
weekly (for 4 weeks
commencing in
January 2021
4b. For an update
to be made to
Nerve Centre
software to ensure
that completion of
all parts of
neurological
observations are
mandatory
Nerve Centre needs to
be amended to ensure
that the completion of
all sections of
neurological
observations are
mandatory
Jan-21
Lead for
Clinical
Information
systems
The update to
Nerve Centre has
been agreed. The
aim is for this to
be "live" week
commencing 18th
January 2021
Update to Nerve
Centre software
On-going
Feb-21
5. For all of the
above actions to
be included in
mandatory falls
prevention and
management
training for all
clinical staff
Falls training to be
made mandatory for
all clinical staff and for
the above actions to
be part of this
training. This policy is
also to be added to
the training provided
by the anticoagulation
pharmacists.
On-going
For clinical staff to
be up to date with
mandatory falls
prevention and
management
training
Lead Nurse
for Falls
Prevention
The process to
make falls
prevention and
management
training
mandatory for all
clinical staff has
begun. All training
packages (face to
face and e
learning) will be
amended to
include the above
actions). Current
face to face
sessions provided
by the Lead Nurse
for Falls
Prevention
includes discussion
on anticoagulation
and the
requirement for
the completion of
neurological
observations
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