Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0072, written 12 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 | 12 Mar 2021 |
|---|---|
| Reference | 2021-0072 |
| Deceased | Elizabeth Robinson |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| 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.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. (cid:9) Chief Executive, Aneurin Bevan University Health board 1 CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 2 3 1 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 31/10/19 an investigation was opened into the death of Elizabeth Joyce ROBINSON The investigation concluded at the end of the inquest on: 4/3/21 The conclusion of the inquest was recorded as: Death By Accident The medical cause of death was: 1a) Subdural haemorrhage with subfalcine herniation. 1b) In patient fall sustaining head trauma. 1c 2 Cognitive impairment, Coronary artery bypass graft, aortic dissection with repair. 4 CIRCUMSTANCES OF THE DEATH Elizabeth Robinson was an 87-year-old lady who had led an active and independent life until early 2019 when she seemed to develop signs of dementia. On 17th July 2019 she sustained a fractured hip and was admitted to Prince Charles Hospital where she underwent surgery. On 6th September 2019 Mrs Robinson was transferred to Ysbyty Ystrad Fawr (YYF) for ongoing rehabilitation. Mrs Robinson was at high risk of falls and at approximately 02:30 hours on 21st October 2019, Mrs Robinson got out of bed, fell and hit her head sustaining a fatal head injury. Mrs Robinson was kept under observation but deteriorated rapidly at 06:30 hours when she was discovered to be unresponsive. A CT scan at that time confirmed an extensive cerebral bleed and sadly she died later that day at 17:30 hours 5 CORONER'S CONCERNS During the course of the inquest, 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. Staffing Levels Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling. Whilst the documentation was not completed, two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients. Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist. 2. Serious Concerns report findings At the inquest, Mrs Rowlands described the omissions in the falls risk assessment process and the steps that are now being taken to ensure that staff complete the documentation properly. It is my understanding that the internal investigation is an essential component of organisational learning to improve the quality of care to patients and also prevent future deaths. Mrs Rowlands informed me that falls were the greatest risk posed to patients by (cid:9) the Health Board. I was therefore concerned to hear that neither of the nursing staff who gave evidence had seen the findings of the internal investigation some 1 years and 4 months since Mrs Robinson's death. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: 1. Confirm whether any steps have or will be taken to address the staffing levels on Oakdale Ward at YYF. 2. Describe how the findings and learning from the internal investigations are shared in a meaningful and timely manner with all grades of clinical staff. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely I, the Coroner, may extend this 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 necessary S COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) . The family of Elizabeth Robinson 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 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 DATE 12/3/21 Signed Caroline Saunders Her Majesty's Senior Coroner for the Area of Gwent.
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.
DS G IG Bwrdd lechyd Prifysgol Aneurin Bevan y? N HS University Health Board Our | 7 May 2021 Ms Caroline Saunders Room 204W The Civic Centre Godfrey Road Newport NP20 4UR Dear Ms Saunders Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Mrs Elizabeth Joyce Robinson. Thank you for your report of 12 March 2021, outlining your concerns following the inquest of Mrs Elizabeth Robinson. I am sorry that it has been necessary for you to raise these concerns and I seek to address these in this response. 1. Staffing levels on Oakdale Ward, Ysbty Ystrad Fawr Aneurin Bevan University Health Board (ABUHB) has processes in place across its sites to escalate any staffing deficits within a planned roster and/or any requests for additional staffing requirements. At the time of Mrs Robinson’s fall, a Nurse Staffing Escalation Policy (NSEP) was in place. This articulates everyone’s responsibility to maintain appropriate nurse staffing levels and sets clear actions if there is a deviation from what is required. Having reviewed the roster on the night of 20-21 October 2019, when Mrs Robinson fell on Oakdale Ward, it is noted that the planned nursing roster was met. There is clear evidence, by way of the health roster, that there was a request for additional staffing to support the provision of enhanced care and that this was escalated, acted upon by the Ward Sister, sent to the resource bank and the shift was subsequently filled to support this requirement. Therefore all reasonable steps were taken to manage the known staffing deficits. The Health Board acknowledges that enhanced care is a challenge and consequently, in September 2020, established an Ysbty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool, in order to support the enhanced level of care required. Pencadlys Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport South Wales NP18 3XQ Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd lechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Health Board Ms Caroline Saunders 2 7 May 2021 Staff were employed on a substantive basis, as opposed to a temporary basis, therefore improving continuity in care and patient safety. A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevil Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements. By way of assurance, the Health Board has in place the following to review and maintain nurse staffing levels: e A NSLWA Operating Framework and Staffing Escalation Process, the purpose of which is to standardise and inform staff groups of their responsibilities also of processes and procedures for ensuring appropriate and carefully considered nurse staffing in all areas. e A weekly reporting and escalation process by means of the Executive Safety Huddle by which all staffing deficits across the Health Board are reported. A comprehensive report is shared, which includes any incidents resulting in harm which may have been attributed to nurse staffing levels. e The establishment of HCSW pools on Community Hospital sites to support the deployment of staff - taking all reasonable steps to ensure planned rosters were maintained on a backdrop of significant absenteeism and fluctuation in capacity required to manage the pandemic. The recruitment strategies deployed within ABUHB to address the vacancy factor has placed the Health Board in a far more positive position. March 2021 reports a vacancy factor of 165.45WTE Registered Nurse vacancies — with a projected forecast of 121.32WTE vacancies by August 2021. In addition to the extensive work on the recruitment of Registered Nurses the Health Board has also supported a significant move to increase the substantive HCSW workforce across all specialities. An additional 145WTE HCSW’s have been employed since July 2020, providing continuity in care and improved patient experience. 2. Serious Concerns report findings Unfortunately, in this instance, the investigation report into the events leading to Mrs Robinson’s death was not shared with the staff involved in a timely manner. However, a falls thematic review for Ysbty Aneurin Bevan (YAB) Ms Caroline Saunders 3 7 May 2021 and YYF was established following this incident and interim post-fall guidance has been widely shared with medical and nursing staff across the Health Board to ensure awareness of, and compliance with Health Board policy. Whilst the report itself was not shared with the staff involved, the broader findings have been shared widely. Serious Incident investigations can be undertaken by an individual Division or by the Health Board’s Corporate Serious Incident Team, which is part of the Putting Things Right Team. An example of good practice is the Mental Health and Learning Disabilities Division which meets fortnightly to review unexpected deaths, serious incidents, safeguarding matters and other concerns, ensures that patients, family members and staff members involved in an incident are supported following often distressing incidents and that staff involved are provided with feedback on any incident report findings. Nonetheless, it is acknowledged that there has been some variation within the Health Board as to how investigations are carried out as some investigations are carried out by the Health Board’s Corporate Serious Incident Team, whilst others are carried out by individual Divisions. To address this, the Corporate Serious Incident Team has been working hard to create a standard approach for its own use and for the Divisions to follow. This has involved implementing a training programme for Investigating Officers to ensure that investigations are carried out thoroughly. This programme was temporarily paused during the second wave of the pandemic whilst clinical work was prioritised, but has recently recommenced. In addition, the Team is trialling standardised template agendas for use at Serious Incident investigation meetings to act as prompts to ensure that key points such as sharing report findings with stakeholders and with individual staff involved are implemented. A copy of these is enclosed. These templates will be reviewed, modified to reflect any feedback from the trial phase, and shared for use across the Health Board. I trust that this information addresses the concerns raised in your report, however please do not hesitate to contact me should you require any further information. Yours sincerely Dirprwy Brif Weithredwr/Cyfarwyddwr Cyllid a Pherfformiad Deputy Chief Executive/Director of Finance & Performance
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