Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0280, written 9 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Dec 2020 |
|---|---|
| Reference | 2020-0280 |
| Deceased | Leslie Harris |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Public Health England and NHS CORONER | am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South CORONER'S LEGAL POWERS | 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 INVESTIGATION and INQUEST On 26" May 2020 | commenced an investigation into the death of Leslie Harris. The investigation concluded on the 23 November 2020 and the conclusion was one of Narrative: Died from Covid 19 pneumonia, | acquired whilst an inpatient at Stepping Hill Hospital, contributed to by the complications of an accidental fall. The medical cause of death was 1a) Covid 19 pneumonia Il) Right sided neck of femur fracture, Hypertension, Atrial fibrillation la | CIRCUMSTANCES OF THE DEATH | Leslie Harris was admitted to Stepping Hill Hospital following an accidental fall at his home address. He underwent surgery for a fractured hip. Post operatively, he was unwell with a chest infection. He began to recover and was considered fit for discharge to the Cavendish unit. Whilst an inpatient, he was moved to another ward, and then moved back as the outlier ward was not felt to be appropriate for his needs. On his return, he was put on a bay where patients had been exposed to a Covid 19 positive patient. He subsequently tested positive for Covid 19. He deteriorated rapidly and died at Stepping Hill Hospital on 21st May 2020. |_| 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. — The inquest heard that he was moved to a ward where other patients were in isolation from Covid due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way the trust have changed their policy and such movement no longer takes place. However, the guidance from PHE has not been amended and it was unknown how ather trusts were choosing to interpret the guidance and as such putting potentially vulnerable patients at risk of developing Covid 19 whilst an in-patient. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 3" February 2021. |, 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 | have sent a copy of my re ief Coroner and to the following Interested Persons namely the daughter of the deceased, who may find it interest. | 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. Alison Mutch HM Senior Coroner for Manchester South 9 December 2020 Nt (IM tN
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.
Ms Alison Mutch
HM Senior Coroner for Manchester South
Coroner’s Court,
1 Mount Tabor Street,
Stockport
SK1 3AG
National Medical Director
Skipton House
80 London Road
SE1 6LH
9th February 2021
Dear Ms Mutch,
Re: Regulation 28 Report to Prevent Future Deaths – Mr Leslie Harris (died 21
May 2020)
Thank you for your Regulation 28 Report dated 9th December 2020 concerning the
death of Leslie Harris on 21st May 2020. Firstly, I would like to express my deep
condolences to Mr Harris’s family.
The regulation 28 report concludes Leslie Harris’s death was a result of COVID 19
pneumonia acquired whilst an inpatient at Stepping Hill Hospital, contributed to by
the complications of an accidental fall.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS
England regarding there is a risk that future deaths will occur unless action is taken.
The inquest heard that Mr Harris was moved to a ward where other patients were in
isolation from COVID-19 due to the interpretation of the Public Health England
guidance about management in these circumstances. As a result of reflection and
concerns, the trust have changed their policy and such movement no longer takes
place.
Your report states that the guidance from PHE has not been amended and it was
unknown how other trusts were choosing to interpret the guidance and as such
putting potentially vulnerable patients at risk of developing COVID-19 whilst an
inpatient.
The national IPC guidance (COVID-19: Guidance for the remobilisation of services
within health and care settings Infection prevention and control recommendations),
is published by Public Health England (PHE). NHS England and NHS Improvement
are a contributor to the guidance development in accordance with their role as a
NHS England and NHS Improvement
commissioner with a duty to promote a comprehensive health service under the
NHS Act 2006.
The national IPC guidance is updated regularly as and when new scientific
evidence emerges. An updated version was published on 20 August 2020 providing
examples of how organisations can safely manage patients/individuals’ treatment
and care and reduce COVID-19 risks by the use of 3 specific COVID-19 risk
pathways (high, medium and low risk) depending on whether the patient/individual
has tested positive for COVID or is likely to have COVID, has not yet been tested or
is awaiting the result of a COVID test or has tested negative for COVID.
The latest version, published on 21 January 2021, adds to the August guidance by
taking into account evidence on new variant strains and amendments have been
made to strengthen existing messaging and provide further clarity where needed,
including updates to the care pathways to recognise testing and exposure.
The IPC measures recommended within the guidance are underpinned by the
National Infection Prevention and Control Manual (NIPCM) practice guide and
associated literature reviews National Infection Prevention and Control Manual:
Home (scot.nhs.uk) The content is consistent with the administrative measures
outlined in WHO IPC during healthcare when coronavirus disease (COVID-19) is
suspected or confirmed: Interim Guidance, June 2020.
The principles in the guidance apply to all health and care settings. Its
implementation should be underpinned at provider level by risk assessments that
take into consideration the patient, environment, procedure and task being
undertaken by any member of health care staff, and through safe systems of
working: administrative, environmental and engineering measures/controls that
need to be adopted to reduce the risk of transmission, including: personal protective
equipment, hand hygiene, social distancing, cleanliness/decontamination of the
environment and equipment, ventilation and separation and segregation of patient
and staff within the high, medium and low risk pathways.
Further updates may be made to this guidance as new evidence on COVID-19
emerges and as the pandemic phases/levels change.
Thank you for bringing these important patient safety issues to my attention and
please do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England and NHS Improvement
NHS England and NHS Improvement
By email Alison Mutch, Senior Coroner c/o Our ref: Dear Alison Mutch Public Accountability Unit Wellington House 133-155 Waterloo Road London SE1 8UG T www.gov.uk/phe 11 February 2021 Re: Inquest into the death of Leslie Harris on 21st May 2020 Thank you for sending the attached report for Public Health England’s (PHE) consideration. Under the Coroners and Justice Act 2009, please find below PHE’s response in relation to the investigation of the death of Leslie Harris Concern raised This report states that Mr Harris died of COVID-19 pneumonia acquired whilst an inpatient at Stepping Hill Hospital, contributed to by the complications of an accidental fall. It outlines that the inquest heard that he was moved to a ward where other patients were in isolation from COVID-19 due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way, the trust has changed their policy and such movement no longer takes place. It also states that the Public Health England guidance has not been amended and it was unknown how other trusts were choosing to interpret the guidance as such putting potentially vulnerable patients at risk of developing COVID-19 whilst an in-patient. Action taken From the details within the report it is difficult to determine exactly which piece of guidance the trust was using in relation to the care of Mr Harris. PHE publishes guidance on management of staff and exposed patients or residents in health and social care settings, which contains clear advice on segregation of patients who have been exposed to a patient with COVID-19 infection from patients who have not been exposed to the infection. National Infection, Prevention and Control guidance is issued jointly by the four nations. PHE publishes this guidance. Guidance at the time contained information on infection control precautions, including cohorting of patients. This guidance was updated after the sad passing of Mr Harris. Updated versions of the guidance, with most recent updates on 20th August 2020 and 21st January 2021, provide advice on reducing the risk of COVID-19 transmission through use of high, medium and low risk COVID-19 risk pathways determined by risk assessment of individuals based on information including test status. The report states that Mr Harris was put on a bay where patients had been exposed to a COVID-19 patient. PHE has reviewed and updated this guidance several times as the pandemic has evolved. Guidance published on 4th April 2020 stated that in-patients who are known to have been exposed to a confirmed COVID-19 patient should be isolated or cohorted until their hospital admission ends, or until 14 days after last exposure (the recommended isolation period at the time). The wording was further strengthened on 15th May 2020: In-patients who are known to have been exposed to a confirmed COVID-19 patient while on the ward (an exposure similar to a household setting), should be isolated or cohorted (grouped together) with other similarly exposed patients who do not have COVID-19 symptoms, until their hospital admission ends or until 14 days after last exposure. In the current version of this guidance, a further clarification has been added: This also applies to in-patients who have previously recovered from COVID-19 and have been exposed to a confirmed COVID-19 case during their hospital stay. PHE will be further reviewing this guidance to ensure that wording is tightened to prevent any misinterpretation of the advice. I would like once again to convey my condolences to the family of Mr Harris and thank you for raising your concerns. Yours faithfully, FOI team 2
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.