Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0070, written 8 Mar 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Mar 2021 |
|---|---|
| Reference | 2021-0070 |
| Deceased | Rodney Gates |
| Coroner | Kate Thomas |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY 1 CORONER I am Kate Thomas, assistant coroner, for the coroner area of Mid Kent and Medway 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On the 1st May 2018, I commenced an investigation into the death of Rodney Gates aged 84. The investigation concluded at the end of the inquest on 2nd March 2021. The conclusion of the inquest was Misadventure contributed to by neglect 4 CIRCUMSTANCES OF THE DEATH On the 5th April 2018, Mr Gates crossed the A2 High Street, Newington Kent, passing in front of a HGV which was waiting at temporary traffic lights set up to manage traffic flow whilst the carriage way was excavated to repair a leaking water pipe. As he crossed directly in front of the vehicle, it was beckoned forward by the traffic management operative, clipping Mr Gates’ shoulder and causing him to fall to the kerb and sustain injury. He was admitted to Medway Maritime Hospital by ambulance and was diagnosed with fracture of the right proximal femur, which was known to carry a high risk of bleeding, such risk being increased by reason of Mr Gates’ age and coronary artery disease. He was appropriately managed and admitted to the ward at approximately 1 am on the 6th April 2018, with a plan to operate later that day. Throughout, Mr Gates’s blood pressure had been low and although his NEWS score had been zero at the point of entry to the hospital it had risen to 3 at the time he was transferred to the ward. It subsequently dropped to a score of 2 which pursuant to the NEWS protocol required 2 hourly observations as a minimum. In any event the observation rate had been set at every 2 hours by treating clinicians due to the need to monitor for any deterioration due to bleeding at the fracture. Those observations were undertaken until 6.30 am on the 6th April 2018 after which they were not performed again until 1.15 pm ( nearly 7 hours later ) when it was recorded that Mr Gates’ Blood pressure had dropped such that it was apparent that there was a significant and serious bleed from the facture site and which required immediate medical intervention. His deterioration during this 7 hour period had not been identified. Despite appropriate management including transfusions Mr Gates continued to decline and arrested at approximately 3.45 pm and died despite resuscitation attempts. The medical cause of death was 1a Hypovolaemic shock following recent osteoporotic comminuted fracture of the proximal right femur ( awaiting definitive treatment ) in a patient with coronary artery disease and myocardial infarction II Hypercholesterolaemia, road traffic collision 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. – (1) the failure to undertake at all the required observations of a patient pursuant to clinical direction and / or the NEWS protocol which was directly attributable to the conditions of the nursing staff on the ward, those being - (2) the overall low number of nursing staff both within the A&E department and on the ward (3) the reliance on agency nurses (4) the lack of experience and narrow spectrum of skill set of the nursing staff (5) the lack of equipment available to nursing staff on the ward 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation] 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 4th May 2021 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 – nephew of the deceased and representative for the family I have also sent it to the Department of Health and Social and the Care Quality Care Commission 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 8th March 2021 Kate Thomas Assistant Coroner Mid Kent and Medway
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.
MEDICAL DIRECTORS OFFICE PRIVATE & CONFIDENTIAL Ms Patricia Harding Senior Coroner for Mid Kent and Medway Kent Register Office The Archbishop’s Palace, Palace Gardens Mill Street Maidstone, Kent ME15 6YE 31st March 2021 Dear Ms Harding, Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY Regulation 28 Report to Prevent Future Deaths – Rodney Gates Please find below the Trust’s response to the Regulation 28 Notice issued by the Assistant Coroner Kate Thomas on 8 March 2021. Coroner’s Concerns:- (1) The failure to undertake at all the required observations of a patient pursuant to clinical direction and / or the NEWS protocol which was directly attributable to the conditions of the nursing staff on the ward, those being –(2-5) Response:- • Since the index events in April 2018, every inpatient ward area at the Trust has moved to electronic observation recording and an effective red flagging system based on NEWS2 via our networked Extramed system • MHLS [Medway Hospital Life Support] (deteriorating patient training) is now delivered and monitored for all acute ward registered nurses based on NEWS principles • All Band 6 nurses complete the ALERT course which is an advanced deteriorating patient management training program • The Trust now has a well-established acute response team (ART) of expert nursing staff who are available 24hrs a day 7 days a week for escalation of any concerns and management of clinical deterioration in patients • The Trust Band 6 nurses are also trained in Advanced Life Support • Shift to shift nursing handover has been improved to include bedside discussion involving every patient using a new best practice template to improve the quality and effectiveness of this process. (2) The overall low number of nursing staff both within the A&E department and on the ward Response • In 2019, the Chief Nursing Officer commissioned a safe nursing staffing review which identified and resourced increases in the establishment of nursing staff line in accord with national guidelines • The Accident and Emergency department has used best practice workforce tools on an annual basis to ensure safe nursing staffing levels are met since 2017. • The nurse staffing head count in A&E has increased since 2017 threefold with a significant reduction year on year in Bank and Agency staff usage (3) The reliance on agency nurses Response • There is an experienced Ward Manager in post since 2018, who has developed a stable and experienced team with considerable consistent success in recruitment and training reducing agency usage in this area • There are no current Registered Nurse vacancies in Pembroke Ward • Agency staff usage overall in the Trust has reduced from 127 Whole Time Equivalent to 69 Whole Time Equivalent in the last three years. (4) The lack of experience and narrow spectrum of skill set of the nursing staff Response • The reviewed establishment for nursing staff in Pembroke ward which now includes 5 x band 6 Registered Nurses, all with experience and training in orthopaedic nursing has significantly improved the specialised care delivery to patients and supervision of junior nursing staff. • The ward is supported by a professional trauma co-ordinator who delivers advanced clinical skills training to Registered Nurses and medical staff involved in the care of trauma orthopaedic patients informally at the bedside and in regular trauma day training forums. • The A&E Department has recruited resuscitation practitioners working to identify and escalate trauma designated care. • The Department conducts regular complex simulation training including trauma scenarios. Monthly trauma meetings are conducted to review complex case management and the sharing of lessons learned with the broader clinical team including our system partners SECAmb. (5) The lack of equipment available to nursing staff on the ward Response • The Trust has invested in an equipment store after-hours, so that if equipment fails or cannot be located there are now resources continually available to ward nursing staff both during the day and after hours Yours sincerely, Chief Medical Officer
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