Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0215, written 18 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 | 18 Jun 2021 |
|---|---|
| Reference | 2021-0215 |
| Deceased | Leslie Horsfield |
| Coroner | Julie Robertson |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1} REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, The Northern Care Alliance NHS Trust CORONER lam Julie Robertson, Assistant Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On 9 October 2020 an investigation into the death of Leslie Harsfield was commenced. The investigation concluded at the end of the inquest on 29 April 2021, | recorded a conclusion of accidental death. The cause of death 1a) Asphyxiation b) Blockage of airways by vomited stomach contents 2) Pneumonia, Chronic Obstructive Pulmonary Disease, Frailty. CIRCUMSTANCES OF DEATH The deceased, who was then aged 84 years, was admitted to The Royal Oldham Hospital on 1 October 2020, with symptoms of a cough and worsening breathlessness. The Deceased was brought to A&E by paramedics and because of COVID-19 restrictions was not accompanied by a carer or family member. During the early hours of 2 October 2020, an admissions assessment was completed which included consideration of whether the Deceased had any swallowing difficulties. The assessor did not ask the Deceased whether he had experienced episodes of choking in the past and he did not volunteer that information. The evidence was that the Deceased had previously experienced a choking episode in 2018 and been assessed as having a swallowing delay. Based on the assessment undertaken on 2 October 2020, the deceased was assessed as not requiring assistance with eating or drinking, a modified diet or a swallowing assessment. On 3 October 2020, the deceased was noted to be gasping for air following which he vomited suddenly and became unresponsive. Despite. prompt suctioning and medical attention, the deceased died soon after becoming unresponsive. At post mortem, the pathologist noted that food material had clogged in the left bronchus lumen. The pathologist gave evidence that the blockage of the deceased’s airways by vomited stomach contents caused his death by asphyxiation. During the inquest hearing, evidence was given that had the nurse undertaking the admission assessment known about the previous choking episode she would most likely have referred the Deceased to the Speech and Language Therapy Team. CORONER'S CONCERNS At the conclusion of the evidence, | granted the Northern Care Alliance 28 days to file further evidence to address the concern around the admissions assessment tool. That evidence was received by the court on 21 May 2021 and has been taken into account 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 absence of any prompt in the admissions assessment tool which reminds assessors to ask patients about previous choking episodes creates a risk that relevant information is missed from the | assessment and places the onus on the patient to volunteer information which they may not appreciate is relevant to the assessment + In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 6 ACTION SHOULD BE TAKEN 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 13 August 2021 |, Julie Robertson, the Assistant Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. | eterise you must explain why no action is proposed. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- 1. Family of Leslie Horsfield 2. The Care Quality Commission | 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 from. 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. . t Date: (SF 6-21 Signed: KO
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.
Northern Care Alliance
Trust Headquarters
Salford Royal Foundation Trust
Salford
M6 8HD
Date 15th July 2021
Dear Miss Robertson
Re: Inquest touching the death of Leslie Horsfield
I write further to the above matter following receipt of your Regulation 28 report dated 18 June 2021.
This correspondence constitutes the Northern Care Alliance NHS Group response to that report.
I would like to emphasise that I fully support the use of Regulation 28 reports as an important
mechanism for learning and that as an organisation we are continuously looking for ways to improve
patient safety. I am therefore grateful to you for sharing your concern and for bringing this matter to
my attention.
Having discussed this with senior nursing colleagues within the Trust, it is however maintained that
the nursing admission proforma provides the assessor with the ability to adequately explore a
patient’s swallowing capability. Whilst the nursing assessment does not ask a specific question in
relation to previous episodes of choking, the assessment does clearly question patients in relation
to any problems with eating and drinking, the need for modified dietary consistency, or anything else
to prompt a referral to Speech and Language Therapy.
(Divisional Director of Nursing), in his letter to you dated 21 May 2021, confirmed
that other local Trusts, in their assessment tools, also do not ask this specific choking question. It is
the opinion, of very experienced nurses across the Northern Care Alliance, that the nursing
admission proforma asks sufficient questions relating to swallow for a patient, with capacity, to be
able to volunteer information relating to any choking episodes.
You will of course appreciate that, practically, we cannot legislate within our assessments for every
potential ailment a patient may have and, if we were to try to do that, there is a danger that by being
over-prescriptive, registered professionals will not use their experience and judgment but rather rely
on the form.
I acknowledge that there are lessons emanating from this inquest, these have been shared with our
staff. It is my experience that our employees are always receptive to learning, especially where it
promotes good practice and enhances patient safety.
Having considered the matter further, I would like to provide you with assurance that as part of our
Electronic Patient Record (EPR) Programme roll-out across the North East Sector, the nursing
admission proforma will be updated to ask whether the patient has previously experienced any
choking episodes. The timeframe for implementation of EPR across Pennine is Spring 2023.
We would once again like to thank you for bringing this to our attention. I wonder if there is a
consideration for this to be recommended nationally. Discussions with external organisations has
confirmed this specific question also does not feature within their admission documentation.
Although we believe the risk you describe is adequately managed thought the series of questions
we currently ask, if you remain of the opinion that change is required, should the recommendation
be made national?
I thank you in anticipation and if there is anything else, I can assist you with, please do not hesitate
to let me know.
Yours sincerely
Group Director of Patient Safety & Professional Standards
CC Miss Kearsley, Senior Coroner
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.