Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0239, written 13 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jul 2021 |
|---|---|
| Reference | 2021-0239 |
| Deceased | Valmai West |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| 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 of Aneurin Bevan University Health Board 1 CORONER 2 3 1 am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 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 28/1/2020 an investigation was opened into the death of Valmai Ann WEST The investigation concluded at the end of the inquest on: 1/7/2021 The conclusion of the inquest was recorded as: Death By Accident The medical cause of death was: 1a) Intracranial Haemorrhage 1b) Fall 4 CIRCUMSTANCES OF THE DEATH Valmai West suffered 2 falls in the community on 111h and 16th January 2020 respectively and attended the Emergency Department of the Royal Gwent Hospital. On neither occasion did she present with any signs of intracranial haemorrhage or cerebral irritation. Mrs West had also suffered a fracture of her pubic ramus on 16th January and was admitted to hospital for management of the fracture and rehabilitation. On 20th January Mrs West was found to be unresponsive and a CT scan demonstrated an extensive subdural haemorrhage. The effect of this bleed was devastating and Mrs West died on 22nd January 2020 at the Royal Gwent Hospital. 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. (cid:9) Staffing Levels in the Emergency Department of Royal Gwent Hospital During the course of the inquest, consideration was given to the the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr , Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ' assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk. 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. (cid:9) Confirm whether any steps have or will be taken to address the staffing levels within the Emergency Department or other steps to ensure that there is sufficient capacity to undertake essential duties such as neurological observations. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 06.09.21, 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. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Valmai Ann WEST 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 13/7/21 Signed Ca2~,, 6 -r 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.
QG Bwrdd lechyd Prifysgol Aneurin Bevan HS University Health Board 3 September 2021 Caroline Saunders Her Majesty's Senior Coroner for the area of Gwent The Civic Centre Dear Ms Saunders Re: Aneurin Bevan University (Health Board response to Regulation 28 Report received following the inquest touching upon the death of Mrs Valmai Ann West, DOB 05/10/1939 Thank you for your report dated 13th July 2021, which was received by the Health Board on the 14th July 2021. The information within the response letter has been compiled by , Executive Director of Nursing. In response to your report, the information provided is intended to address s during the course of the inquest. It the concerns raised by Dr was acknowledged that staff had not followed hospital protocol or NICE guidelines in relation to the frequency of which observations should be performed. Dr assessment of the situation was this was probably due to inadequate nurse staffing levels within the Emergency Department. Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations. I thought it would be helpful to share that an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital was commissioned as a result of the early opening of the hospital and in light of increased patient demand. This has been undertaken by the Bwrdd lechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj Caerilion Casnewydd De Cymru NP15 3XQ Ff6n: 01633 436700 E-best: abhb.enquiries@wales.nhs.uk Aneurin Bevan University Health Board Headquarters St Cadoc's Hospital Lodge Road Caerleon Newport South Wales NP18 3XQ Tel No: 01633 436700 Email: abhb.enquiries@wales.nhs.uk Bwrdd Iechyd Prifysgol Aneurin Bevan yw envy gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board -2- Senior Nurse Manager for ED and the Assistant Head of Nursing, supported by the Deputy Director of Nursing. The assessment is based on RCN Guidance, RCEM Guidance, Nurse Staffing Levels (Wales) Act 2016 and, importantly, professional judgement. A similar review of medical staffing is also being undertaken. I hope this additional information in relation to the matters raised is helpful in terms of clarification but also as an update on progress and assurance in relation to nurse staffing levels within the Emergency Department at the Grange University Hospital and those raised in regards nurse staffing levels at the time of the incident. Do not hesitate to contact me should you require any further information. Yours sincerely Prif Weithredwr/ Chief Executive
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