Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0207, written 17 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jun 2021 |
|---|---|
| Reference | 2021-0207 |
| Deceased | Leonard Pritchard |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: -|1) Chief Executive of University Hospitals Birmingham NHS Trust 2) NHS England CORONER | am Mr Adam Hodson, Assistant Coroner for Birmingham and Solihull CORONER'S LEGAL -_POWERS : 2 | 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 24 February 2021 | commenced an investigation into the death of Leonard Arthur PRITCHARD. 3 The investigation concluded at the end of the inquest. The conclusion of the iriquest was Accidental Death. CIRCUMSTANCES OF THE DEATH The deceased died on 18.February 2021 in Good Hope Hospital, Sutton Coldfield, as a result of injuries which he sustained following an unwitnessed fall from a chair in an A&E cubicle on 12 February 2021. He was treated conservatively, but his condition deteriorated over the course of the following days and sadly he did not recover. He was originally admitted as a precaution following an unwitnessed fall at his care home earlier on 12 February 2021, where CT scanning indicated that he did not sustain any acute intracranial injury at that time. He was subsequently assessed in the emergency department as being at.a risk of falls by the nursing staff, who implemented appropriate falls prevention measures. He was not provided with a zimmer frame to allow him to mobilise, and no discussion took place between staff as to how he was to mobilise in the absence of a walking aid. Based on information from the Deceased's treating clinicians the medical cause of death was ~ Idetermined to be: 1a PNEUMONIA 1b INTRACRANIAL HAEMORRHAGE 4c FALL ll ATRIAL FIBRILLATION (ANTICOAGULATED), HYPERTENSION, TYPE 2 DIABETES MELLITUS, ISCHAEMIC HEART DISEASE, DEMENTIA” : ‘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 itis my statutory duty to report to you. "| The MATTERS OF CONCERN are as follows. - 1. During the course of the inquest, | heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patient's mobility, and which are given to patients who are identified as requiring an aid. | heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the the emergency department; and 8 chairs in the clinical decision unit. | heard from staff that they consider this mobility aid to patient bed ratio was inadequate. There is a clear risk of death for patients who require mobility aids but can not have access to them. The Trust should consider addressing this as a matter of urgency. 2. Linked to 1) above, | heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by. The Trust should consider ensuring that this procurement process takes places as a matter of urgency. 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 12 August 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 report to the Chief Coroner and to the following Interested Persons:~- Family of Mr Pritchard. | 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 goroner, at the time of your response, about the release or the publication of your response hief Coroner, 17 June 2021 Signature: Adam Hodson Assistant Coroner for Birmingham and Solihull
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.
Mr Adam Hodson Assistant Coroner for Birmingham and Solihull 50 Newton Street Birmingham Interim Chief Executive, NHSI & National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 21 October 2021 Dear Mr Hodson, Re: Regulation 28 Report to Prevent Future Deaths – Leonard Arthur Pritchard 18 February 2021 Thank you for your Regulation 28 Report dated 17 June 2021 concerning the death of Leonard Arthur Pritchard on 18 February 2021. Firstly, I would like to express my sincere condolences to Mr Pritchard's family. The recent inquest concluded Accidental Death with Mr Pritchard’s death a result of 1a Pneumonia 1b Intracranial Haemorrhage 1c Fall II Atrial fibrillation (anti-coagulated), hypertension, Type 2 diabetes mellitus, ischaemic heart disease, dementia. Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding: 1.During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patients mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from the staff that they consider this mobility aid to patient bed ration was inadequate. There is a clear risk of deaths to patients who require mobility aids and can not have access to them. The Trust should consider addressing this as a matter of urgency. NHS England and NHS Improvement 2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by. The Trust should consider ensuring this procurement process takes place as a matter of urgency. I note that your Regulation 28 Report was also sent to University Hospitals Birmingham NHS Trust. The Trust have kindly shared their response and I have seen that the matters of concern have been dealt with and responded too at a local level. Given the content and adequacy of the Trust’s response I do not propose responding further on a national level. However I can confirm that we have shared this Regulation 28 Report and both responses with the Regional NHSE/I teams to ensure that they have sight of this potential problem and will ensure that the ED departments in their hospitals have access to an adequate supply of mobility aids. Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information, and especially if you consider there still to be any concern on a national level that needs responding too. Yours sincerely, Interim Chief Executive, NHSI & National Medical Director
4 August 2021 For the attention of Mr Adam Hodson Assistant Coroner for Birmingham and Solihull 50 Newton Street Birmingham Dear Mr Hodson, Inquest touching the death of Leonard Arthur Pritchard Response to Regulation 28 Report to prevent future deaths I write in response to the Regulation 28 Report made by you following the Inquest touching the death of Mr Pritchard which concluded on 17 June 2021. University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths which surround the availability and procurement of mobility aids within the emergency department (ED) at Good Hope Hospital. Supply and procurement of mobility aids I am aware that during the Inquest you heard evidence which suggested that there was an inadequate supply of mobility aids available for use within the ED at Good Hope Hospital. Whilst actions had been agreed, following the RCA investigation, to procure and ensure that mobility aids were available in ED, there unfortunately remained outstanding issues to be addressed between our ED and Older Person’s Assessment and Liaison (OPAL) teams which resulted in slow progress. I can however confirm that immediately following the Inquest 5 zimmer frames were sourced internally and were made available for immediate use within the ED the same evening. The OPAL team also obtained 5 zimmer frames, meaning that there were a total of 12 frames (inclusive of 2 existing frames) immediately available for patients within the department, which was deemed to be an appropriate number. A request for a further 10 frames to be procured was also made on 17 June by the ED team. It is now the responsibility of the ED team to procure additional mobility aids and these can be requested as and when a need is identified. The frames are also stored within the sister’s office situated within the ED, which can be accessed for use at any time. Standardisation of process Following the Inquest we have also standardised the process across all of our sites so that all ED areas have a stock of zimmer frames and a process in place to ensure that patients are provided with a frame when they are assessed as needing one. The process includes the procurement, storage, labelling and auditing of their use. To provide further detail, once a patient has been reviewed by OPAL in any one of our ED areas and is identified as needing a frame, the OPAL team will obtain the frame and attach a label to it confirming the patient’s level of dependency, for example, requires assistance of 1, so that this information is readily available to those caring for the patient. The OPAL team will also inform the ED nurse looking after the patient that a frame has been provided and this will also be documented within the medical records. As the OPAL service is not a 24/7 service, the process also provides for frames to be supplied by the ED teams utilising the stock of frames within each department. The above process was fully implemented in early July and was communicated to all staff within the ED and OPAL team via internal communications. The process also provides for the procurement of additional zimmer frames by the ED teams should additional frames be required. To ensure the above process is embedded across all of our sites and to assess the overall effectiveness of the new process, we have also put in place 6 monthly audits which will look at the number of patients assessed as needing a walking aid, whether they were provided with one in ED and if they weren’t, the reason for this. The first audit is planned to take place in January 2022 with the audit results being presented at our Trust Care Quality Group which is chaired by myself. I would like to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously which I hope is demonstrated by the steps that were taken immediately following the Inquest together with the procurement of additional supplies and the introduction of a new process across all our sites. Yours sincerely, Chief Nurse
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