Prevention of Future Deaths reports · 2021

Ruby Baggaley

Regulation 28 report to prevent future deaths, reference 2021-0044, written 16 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Feb 2021
Reference2021-0044
DeceasedRuby Baggaley
CoronerKevin McLoughlin
Coroner areaWest Yorkshire (E)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedLeeds Teaching Hospitals NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Leeds Teaching Hospitals NHS Trust

1 | CORONER

| am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (E).

2 | 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.

3 | INVESTIGATION and INQUEST

On 30th January 2020 | commenced an investigation into the death of Mrs Ruby
Baggaley, aged 90. The investigation concluded at the end of the Inquest on Monday
15h February 2021. The Inquest resulted in a Narrative Conclusion which records
aspects of her care in the hours after surgery was completed. The cause of death was:

1a Myocardial Infarction
b Hypotension
c Right Distal Femoral Facture (osteoporotic)
Il Angina, Atrial Fibrillation, Hypertension, Previous Stroke and Frailty

4 | CIRCUMSTANCES OF THE DEATH

Mrs Baggaley aged 90 sustained a facture to her right distal femur on 17 January 2020
in a fall at home. On 24 January 2020 she underwent complex surgery at a specialist
centre involving a prosthetic replacement of her knee and a portion of her femur. She
was stable following the surgery with an acceptable blood pressure.

When taken back to the ward and assessed at 16:54 hours her blood pressure was
abnormally low and remained so. This issue was not escalated to a senior colleague
until approximately 21:30 hours, by which time she was in a critical condition. She died
at 22:25 hours that night in the hospital.

5 | CORONER’S CONCERNS

My concerns relate primarily to the care and treatment provided for Mrs Baggaley in the
hours after her complex surgery had been completed. The concerns which were raised
at the Inquest are:-

1) On completion of the surgery Mrs Baggaley was deemed to be in a stable condition
with a blood pressure of 105/49 and a NEWS Score of 3. She was transferred back
to the ward at approximately 16:00 hours. In the following five hours she was
located in a bed remote from the nurses’ station and was not checked frequently (as
might validly be expected in the case of a frail 90 year old lady who has just
undergone major surgery).

2) In the four times her blood pressure was checked between 16:00 hours and
approximately 20:45 hours it was abnormally low. Her urine output was poor.

In the period from 17:00 hours onwards her care was exclusively in the hands of a
relatively junior doctor (CT2) and the nursing staff. No attempt was made to inform
the surgeons or anaesthetist of the deterioration in her condition.

3) Between 16:00 hours and 20:45 hours Mrs Baggaley’s NEWS Score was 5 and
remained at this level. No attempt was made to escalate her care to more senior
clinicians.

It is not clear whether junior doctors and nursing staff now have clear instructions on
when to escalate care in such circumstances, nor to whom.

4) By the time the surgeon was informed of the situation and travelled into the hospital
around 22:00 hours Mrs Baggaley’s condition had become critical.

It is not clear whether earlier intervention by senior clinicians would have avoided
Mrs Baggaley suffering a cardiac arrest consequent upon her low blood pressure
(as the Inquest was informed was the case). It is the case, however, that she was
deprived of the opportunity to have a review by a senior clinician.

5) [am concerned that in the absence of precise information as to what, if any changes
in escalation procedures have been implemented, or additional training provided to
the staff involved, the potential for a comparable situation to occur again, remains.

6) Although it is accepted the following factors did not contribute to Mrs Baggaley's
death, they served to undermine the trust and confidence of her family in relation to
the quality of care provided (particularly when contrasted with that at Leeds General
Infirmary).

° A delay in providing pain relief when she arrived at Chapel! Allerton Hospital
on the evening of 20 January 2020.

e The delay in providing a Nimbus Mattress.

e The delay in arranging traction at Chapel Allerton Hospital, despite this
having been written in her Care Plan and being in place when she was in
Leeds General Infirmary. The evidence given by a family member was that
she was told no-one with the requisite skill was available at the hospital.

e The cancellation of the surgery arranged for 23 January 2020 on the day it
was to take place. This was lamentable not only for a frail 90 year old |
patient who was in pain, but was also a calamity for the efficient use of NHS
resources: a theatre unused for a day; two surgeons each with a day
wasted; an anaesthetist’s time wasted and one less patient treated overall.

it was certainly acknowledged at the Inquest that Mrs Baggaley’s right sided distal
femoral replacement surgery was appropriately classified as a high risk procedure. Her
care was discussed in two surgical forums before she gave written consent to proceed.
The Court applauded the willingness to embark on such surgery. There is little point,
however, in investing in surgery of this nature if the post-operative care is not of a
comparable standard.

The Trust's response to the family's complaint proclaimed that Chapel Allerton Hospital
was the “optimum environment’ for Mrs Baggaley’s treatment “as the ward nursing staff
are also skilled in caring for patients who have undergone this type of surgical procedure”
(letter 7 August 2020, Page 2). The evidence taken at the Inquest does not support
these contentions. It is for this reason that this Regulation 28 Report is submitted to
assist your review of post-surgical care.

6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | 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 Monday 12 April 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.

8 | COPIES and PUBLICATION

‘SIGNED: |

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

| 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.

Ken ER

KEVIN McLOUGHLIN
Senior Coroner
West Yorkshire (E)

Dated: 16" February 2021

Responses

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.

Response from St Jamess University Hospital (PDF)
Date: 9th April 2021 

Mr Kevin McLoughlin 
Senior Coroner 
West Yorkshire (Eastern) 
Coroner’s Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Mr McLoughlin 

Chief Medical Officer 
Trust Headquarters 
St James’s University Hospital 
Beckett Street 
Leeds 
LS9 7TF 

www.leedsth.nhs.uk 

INQUEST TOUCHING THE DEATH OF RUBY BAGGALEY (Deceased) 

I refer to your correspondence of 16th February 2021, regarding the inquest touching the death of Mrs Ruby 
Baggaley and the Regulation 28 Report to Prevent Future Deaths in respect of this case. 

I  can  confirm  that  the  contents  of  your  Regulation  28  Report  have  been  shared  with  the  relevant  staff  to 
enable us to provide you with a comprehensive response.   

In your report you highlight that your matters of concern were as follows: 

(1)  On  completion  of  surgery  Mrs  Baggaley  was  deemed  to  be  in  a  stable  condition  with  a  blood 
pressure of 105/49 and a NEWS score of 3. She was transferred back to the ward at approximately 
16.00 hours. In the following five hours she was located in a bed remote to the nurses’ station and 
was not checked frequently (as might validly be expected in the case of a frail 90-year-old lady who 
has just undergone major surgery). 

(2)  In the four times her blood pressure was checked between 16.00 and approximately 20.45 hours it 
was  abnormally  low.  Her  urine  output  was  poor.  In  the  period  from  17.00  hours  onwards  her  care 
was exclusively in the hands of a relatively junior doctor (CT2) and the nursing staff. No attempt was 
made to inform the surgeons or anaesthetist of the deterioration in her condition.  

(3)  Between  16.00  hours  and  20.45  hours  Mrs  Baggaley’s  NEWS  score  was  5  and  remained  at  this 
level.  No  attempt  was  made  to  escalate  her  care  to  more  senior  clinicians.  It  is  not  clear  whether 
junior  doctors  and  nursing  staff  now  have  clear  instruction  on  when  to  escalate  care  in  such 
circumstances, nor to whom. 

(4)  By the time  the surgeon was informed of the situation and travelled  into the  hospital around 22.00 
hours  Mrs  Baggaley’s  condition  had  become  critical.  It  is  not  clear  whether  earlier  intervention  by 
senior clinicians would have avoided Mrs Baggaley suffering a cardiac arrest consequent upon her 
low  blood  pressure  (as  the  inquest  was  informed  was  the  case).  It  is  the  case,  however,  that  she 
was deprived of the opportunity to have a review by a senior clinician. 

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital, 
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James’s University Hospital, Wharfedale Hospital. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (5)  I am concerned that in the absence of precise information as to what, if any changes in escalation 
procedures  have  been  implemented,  or  additional  training  provided  to  the  staff  involved,  the 
potential for a comparable situation to occur again, remains. 

(6)  Although it is accepted the following factors did not contribute to Mrs Baggaley’s death, they served 
to  undermine  the  trust  and  confidence  of  her  family  in  relation  to  the  quality  of  care  provided 
particularly when contrasted with that at Leeds General Infirmary) 

•  A delay in providing pain relief when she arrived at Chapel Allerton Hospital on the evening 

of 20 January 2020 

•  The delay in providing a Nimbus mattress 
•  The delay in arranging traction at Chapel Allerton Hospital, despite this being written in her 
Care Plan and being in place when she was in Leeds General Infirmary. The evidence given 
by a family member was that she was told no-one with the requisite skill was available at the 
hospital.  

•  The  cancellation  of  the  surgery  for  23  January  2020  on  the  day  it  was  to  take  place.  This 
was  lamentable  not  only  for  a  frail  90-year-old  patient  who  was  in  pain,  but  was  also  a 
calamity  for  the  efficient  use  of  NHS  resources:  a  theatre  unused  for  a  day;  two  surgeons 
each with a day wasted; an anaesthetist’ time wasted and one less patient treated overall. 

It  was  certainly  acknowledged  at  the  Inquest  that  Mrs  Baggaley’s  right  sided  distal  femoral  replacement 
surgery was appropriately classified as a high-risk procedure. Her care was discussed in two surgical forums 
before she gave written consent to proceed. The court applauded the willingness to embark on such surgery. 
There  is  little  point,  however,  in  investing  in  surgery  of  this  nature  if  the  post-operative  care  is  not  of  a 
comparable standard. 

The  trust’s  response  to  the  family  complaint  proclaimed  that  Chapel  Allerton  Hospital  was  the  ‘optimum 
environment’  for  Mrs  Baggaley’s  treatment  ‘as  the  ward  nursing  staff  are  also  skilled  in  caring  for  patients 
who  have  undergone  this  type  of  surgical  procedure’  (letter  7  August  2020,  Page  2).  The  evidence  at  the 
Inquest does not support these contentions. It is for this reason that this Regulation 28 Report is submitted to 
assist your review of post-surgical care.  

The Trust response: 

The  Trust  maintains  its  position  that  Chapel  Allerton  Hospital  has  an  important  role  in  delivering  care  to 
surgical  patients,  including  the  provision  of  complex  orthopaedic  arthroplasty  procedures.    As  an  elective 
operating unit, Chapel Allerton has the necessary equipment and trained personnel to deliver such care.  By 
offering  operating  capacity,  it  also  frees  up  theatre  space  at  Leeds  General  Infirmary  for  trauma  cases. 
However,  it  is  accepted  that  not  all  patients  are  suitable  to  be  managed  at  a  peripheral  site  where  out  of 
hours cover is limited. 

In the future, all elderly or frail patients being considered for transfer to Chapel Allerton  Hospital will be the 
subject of an MDT review by a consultant team consisting of surgeons, anaesthetists and orthogeriatricians. 
The  orthogeriatrician  and  anaesthetist  will  determine  the  level  of  risk  for  that  individual  patient.    If  it  is 
determined  that  high-dependency  care  consisting  of  advanced  cardiovascular  monitoring  and/or  organ 
support will be required, the patient will remain at the LGI site and arrangements made for equipment and 
personnel  to  be  transferred  from  Chapel  Allerton.    Patients  requiring  traction  will  not  be  offered  surgery  at 
Chapel Allerton. 

The  MDT  discussion  will  be  documented  on  PPM+  (electronic  patient  record)  and  the  outcome  discussed 
with the patient and next of kin. As part of this MDT discussion, and in line with established good practice, 
the patient’s resuscitation status will be discussed and clarified with the patient and their family. 

Where a patient is considered suitable for transfer to Chapel Allerton Hospital, this decision will be discussed 
with  patient  and  family  members,  with  a  clear  support  plan  documented  in  the  medical  records  including 
detailed pre- and post-operative plans. 

For  elective  patients,  their  suitability  for  surgery  at  Chapel  Allerton  will  be  determined  at  the  surgical  pre-
assessment clinic with specific input from a consultant anaesthetist specialising in this area.  

All  patients  will  have  a  skin  assessment  within  4  hours  of  transfer  and  appropriate  pressure  relieving 
equipment  will  be  ordered  (this  will  be  ordered  at  time  of  agreement  to  transfer  if  the  patient  is  already 
requiring a specialist mattress). 

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital, 
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James’s University Hospital, Wharfedale Hospital. 

 
 
 
 
 
 
 
 
 
 
 
 
 As  a  result  of  your  Regulation  28  report,  the  relevant  specialty  teams  have  considered  your  comments  in 
order to determine what improvements need to be made to ensure the safety of patients at Chapel Allerton, 
including the prompt escalation of concerns should they arise. 

On the day of surgery, the consultant anaesthetist will have the responsibility to clearly define the patient’s 
post-operative  care,  including  NEWS  scores  that  will  require  escalation  to  critical  care  outreach  team  for 
support out of hours. 

During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and 
anaesthetist  responsible  for  the  patient’s  care.    After  18.00  hours  the  escalation  policy  will  be  based  upon 
clear  objective  assessments  of  the  patient’s  physiological  status  using  the  NEWS2  score  and  the  Trust’s 
‘Deteriorating  Patient  Policy’  and  the  ‘Transfer  of  Care  Policy  for  Chapel  Allerton  Orthopaedic  Centre’.    A 
separate  policy  is  being  developed  to  specifically  address  the  deteriorating  patient  being  cared  for  in 
peripheral  hospital  sites.  Plans  are  on-going  to  establish  a  dedicated  on-call  consultant  rota  for  Chapel 
Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice 
and if necessary, review the patient. In addition, contact details for the operating surgeon and anaesthetist 
will be available to the ward staff if required. Plans are in place to extend the anaesthetic and recovery unit 
cover  on  site  until  21.00.    This  will  facilitate  the  post-operative  reviews  and  management  of  higher  risk 
patients.    Where  possible,  higher  risk  patients  will  be  operated  on  early  in  the  day  to  allow  an  extended 
period of observation before the treating surgeon and anaesthetist leave the site.  In addition, every effort will 
be made to ensure higher risk patients are not operated on at the end of the working week (i.e. on Friday). 

It is recognised that a rolling programme of staff education will be required to support the implementation of 
these planned changes.  All staff in both the operating theatres and surgical wards will have regular training 
on escalation pathways and resuscitation.  There will be compulsory mandatory training for the junior doctors 
starting their post at Chapel Allerton Hospital.  This will be recorded on the Electronic Staff Records. 

Thank you for raising the additional points of family concern, regarding the administration of pain relief and 
the provision of traction and appropriate mattress care. These concerns have been dealt with in the Trust’s 
complaint  response  and  we  are  happy  to  discuss  these  matters  further  with  Mrs  Baggaley’s  family  if  that 
would be helpful.  

With regards to the efficient use of NHS resources, I would like to reassure you that the Trust takes this very 
seriously  and all episodes  of short notice cancellation are reviewed by the  management team.  It  must  be 
said, however, that on rare occasions new issues outside the control of the treating team  can come to light 
which will prevent the surgery going ahead safely.  An example of this would be where a  patient does not 
follow an instruction to stop blood thinning medications prior to the day of surgery.  The Trust does strive to 
minimise such cancellations.   

Thank you for bringing these matters to my attention.  I do hope that this response has assured you that the 
Trust has given careful consideration to the matters of concern you have raised. 

If I can be of any further assistance, please do not hesitate to contact me. 

Yours sincerely 

Chief Medical Officer 
Leeds Teaching Hospitals NHS Trust 

cc.  

Medical Director – Risk and Governance 
Leeds Teaching Hospitals NHS Trust 

Trust Risk Manager 
Leeds Teaching Hospitals NHS Trust 

Director of Quality 
Leeds Teaching Hospitals NHS Trust 

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital, 
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James’s University Hospital, Wharfedale Hospital.

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