Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0211, written 21 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 | 21 Jun 2021 |
|---|---|
| Reference | 2021-0211 |
| Deceased | Elsie Woodfield |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
University Hospitals Plymouth NHS Trust , Chief Nurse & Director of Integrated Clinical Professions University Hospitals Plymouth NHS Trust Derriford Road Crownhill Plymouth PL6 8DH t. · 16!h June 2021 Mr I Arrow HM Coroner 1 Derriford Business Park Breast Road Plymouth PL6 5QZ Dear Mr Arrow Re: Elsie Woodfield I write further to the inquest inbMrs Woodfield's death, which concluded on 8 June 2021. This letter deals with concerns raised by the family in submissions· to the Coroner with regard to his duty to write a Prevention of Future Deaths report to the Trust. In an ema·u dated 10th June 2021 from family concerns were summarised: . . • The divergence in terms of consenting process/content for endoscopy processes . between and complications and the other s_aying they always do. with one saying they never advise of fatal · • The sip test intervention was indicated according to the evidence of but was not done. • An unidentified doctor saw the endoscopy report on the ward and took no action. It was never established who -that docto·r was and so it has. not been explored as to whether steps need to be taken to prevent a recurrence. /M!lfDFUL VEMPLOYER Working in partnership with the Peninsula Medical School " Record keeping concerns. A number of clinicians had failed to maintain proper record keeping and it seems these issues were not explored further once recognised. Divergence in terms of consenting·process · · The issue of consent regards .death as· a possible outcome df this endoscopy procedure has evolved over the last few years. As explained by in his evidence, death is not an expected outcome and is rare. Therefore, many clinicians would not have included death when obtc~ining patient consent. The law following the case of now suggests that all 'material risks' should be discussed with a patient i.e. ~mything they feel would be important to know as a possibl~ outcome. Previously, what was considered appropriate to discuss with a patient when obtaining consent. wa~ interpreted as being on the basis of what a significant body of opinion might say: · · 1 ·currently the plan of the organisation is to move to procedure specific consent where possible and appropriate. We are looking to engage ·with external providers who produce consent and procedural information that are specific to particular procedures. In that way, rather than individual clinicians using their clinical discretion as to what to discuss with patients, standardised information is given · each time· a patient consents, ensuring all material information is given. For those undergoing elective surgery, it also allows more time for patients to read at their leisure the information provided, so they have time to digest and absorb the relevant information before signing to. say they would wish to proceed. The current consent guideline at UHP is in line with the British Society of Gastroenterologists (BSG) 2016 a,nd does not expressly the mention mortality1. However after consultation with the Endoscopy stakeholders and learnfng from other incidents, University Hospitals Plymouth has amended the procedure specific consent forms to include: Although very rare, complications arising from endoscopy procedures can result in death particularly if there are other significant health related problems. In endoscopy there have been procedure specific consent forms since 2008, which have pertinent information. The updating of the procedure specific, consent form has been particularly. important as this is provided tp patients in advance of their· procedure and in advance of talking to the endoscopist on the day. Inpatients (patients that have. come through the emergency care,pathway) are provided with this information on .the ward. and it is also reinforced by endoscopy nurses prior to entering the procedure·room. The ward consultants looking after upper gastro-intestinal bleed patients like Mrs·Woodfield are senior gastroenterologists and endoscopists. One of the main reasons the Trust has a. gastroenterologist specialty medical take is that .these individuals are experienced in assessing risk of the procedure versus the risk of not undergoing the procedure, e.g. assessing urgency and appropriateness. In the vast majority of cases there is good eviqence that early endoscopy improves outcome and is instrumental to the management of. patients with upper GI bleeding in particular those with s,ignificant comorbidities (High Rockall scores) and those on anticoagulants. This is discussed with patients prior to referrimg for endoscopy (and as such is part of the consenting process) and is usually a straightforward discussion but . may be i:nore detailed where there are patient specific concerns, The documentation of this discussion in the notes should certainly be improved. Occasionally a decision will be made not to proceed to endoscopy after discussion with patients and next of kin where the risks· outweigh the benefits. The documentation of this 'not treating' is largely on the whole better . than when the decision is 'for treatment' and is one ofthe learning points. 1 BSG (2016) - Guideline for obtaining consent for Gastrointestinal endoscopy proced.ures /MIHDFUL yeMPLOVffl Working in parlnership with the Peninsula Medical School The mo$t pertinent passage from the 2016 national guidance is this: The test of materiality is procedure, circumstance and patient-specific. The test must be patient-centred, since _the ris~ that can influence a patient's decision can vary from one patient to the next and requires careful Judgement and individual discussion. Thus, it is beyond the scope of this document to describe in detail the information in relation to risks, benefits or alternatives that should be provided for specific endoscopic procedures. Similarly, it is not possible to state in this guideline whether specific risks should be mentioned or in numerical terms what level of risk should be described. In . general, however, you must tell patients if the procedure might result in a se.rious adverse outcome, even if the likelihood is very small, and mention less serious side , effects or complications if frequent. Any·risk that is likely to influence the decision of a' · patient should be included. It is important that in meeting these req1,1irements, the patient is not overwhelmed with excessive information, such that they are unable to evaluate the material risks and benefits. The sip test Intervention The use of 'sip' checking, i.e. 'drinking a small amount of water post oesophago-gastro duodenoscopy (OGD) is to indicate that patients are able to. swallow and do not aspirate liquid into the lungs before being allowed to eat. This is part of basic care and doesn't constitute a diagnostic procedure, merely an aid to support post recovery after an OGD. The sip check is not a test to exclude perforation and the small volume of fluid would not result in mediastinitis. An unidentified doctor saw the endoscopy report on the ward , and two junior doctors, The only medical professionals involved with Mrs Woodfield's care on the ward included the consultant, . did produce a recollection of evehts when the organisation received the complaint letter, which did not refer to him having reviewed the endoscopy report. As I said when giving evidence at the inquest, if the incident had been addressed as a SIRI at the outset, the relevant staff would have been interviewed at the time, when memories were fresh, and the poctor who reviewed the endoscopy report would have been identified. and Record keeping concerns The Trust accepts that elements of the record keeping were poor in this case. All professional bodies have an expectation that individual practitioners will document in the clinical records to 1 an accepted standard. The Trust also has a policy that reflects this expectation: This highlights that responsibility lies with the individual professional and the Trust expects that each indMdual documents in the health records in accordance with the Trust's policy and in line with codes of practice set by professional standards. Nevertheless, the Trust recognises that documentation may suffer during intense wo~king periods and therefore Wf! regularly remind staff at induction and through mandatory training the importance of proper documentation. Clear and regular documentation is part of the induction pack given to juniors working within Gastroenterology (see extract below). Clinical notes (Gastroenterology Junior doctor induction pack) • Ideally, ·each notes entry should start with a diagnosis or a short list of differential diagnoses/problems, followed by a man~gement plan for /MINDFUL VEMPLOYER Working in partnership with the Peninsula Medical School investigation, monitoring and treatment. Record all observations numerically - it shows you have actually looked at them, including respiratory rate as this is often the first thing to "go off" if patients get sick. • Write in the notes daily when the patient is reviewed. • Documentthe reasons behind decision making on ward.rounds . ., Record DNR decisions and ifralevant, how intensively to treat a patient ~g patient tor non-invasive ventilation but not fo(ventilation or ICU. • Document discussions with relatives ideally recording their names & relationship to the patient • Write the results of blood tests in the -notes or update the. flow charts tor · selected patients daily. . • Indicate whether investigations have been requested or are planned, but are not yet reported in the notes. • Take results of current in-patients which you sign to the appropriate wwds during ward round (otherwise results often don't get into the notes during· patient's stay and subsequent transfers of care). • Noles can be used as legal documents. Make entries appropriately and do , not back-date clinical entries. • Stick in a week-end plan for all patients every Friday. This is essential and is regularly audited. • Ensure patients have an estimated date of discharge documented. The Trust accepts that poor record keeping should have been discussed with the individuals at the time of the event to ensure reflective learning. The revised SIR! process will ensure that any similar issues that may arise in the future would be addressed immediately. Yours sincerely ' . , Chief Nurse & Director of Integrated Clinical Professions University Hospital Plymouth NHS Trust 1 5 JUL 2021 . /MIUDFUL yeuPt.OYER Working in partnership with the Peninsula Medical School
OFFICIAL ##DW<<ALLTRIM(cSignedBy)>> ##DW<<ALLTRIM(cSignedByTitle)>> for ##DW<<ALLTRIM(cJurisdiction)>> REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: University Hospitals Plymouth NHS Trust CORONER 1 I am Ian Arrow, Senior Coroner for Plymouth Torbay and South Devon 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST Following an Inquest opened on the 19 December 2017 and an inquest hearing at HM Coroner's Court, Plymouth on the 7 June 2021 heard before Ian Michael Arrow, in the coroner's area for Plymouth, Torbay and South Devon. 4 CIRCUMSTANCES OF THE DEATH The deceased suffered from significant comorbidities in particular ischaemic heart disease. She was determined by her GP to be suffering from Anaemia. She was admitted to hospital for a blood transfusion whilst in hospital, hospital clinicians determined an endoscopy was an appropriate procedure to investigate blood loss. This endoscopy investigation was carried out on 11th of December 2017. The endoscopy investigation was abandoned. On the balance of probability there was a perforation of the oesophagus during the procedure. The deceased developed symptoms of surgical emphysema. She deteriorated and died on 11th of December 2017 at Derriford Hospital, Plymouth. NARRATIVE 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. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy. (2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust. (3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication. (4) Appropriate records were not kept, or were not properly transferred, by senior staff. OFFICIAL 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. Please review the matters of concern in para 5 above. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16 August 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 Ms Woodfield’s family. I have also sent it to Derriford Hospital 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 Dated 21.06.2021 Signature_________________________
See every Prevention of Future Deaths report matching University Hospitals Plymouth NHS Trust, 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.