Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0244, written 15 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 | 15 Jul 2021 |
|---|---|
| Reference | 2021-0244 |
| Deceased | Catherine Best |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath & Port Talbot |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NO TE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEAL TH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR CORONER I am Aled Gruffydd, Assistant Coroner, for the coroner area of SWANSEA NEATH & PORT TALBOT 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. 3 INVESTIGATION and INQUEST On the 3rd July 2012 I commenced an investigation into the death of Catherine Jane Best. The investigation concluded at the end of the inquest on the 9th July 2021. The medical cause of death is 1 a 1 b) 1 c} anoxic brain injury cardiac arrest malnourishment and sepsis The conclusion of the inquest as to how Ms Best came to her death was a narrative conclusion and is as follows:- The deceased was pronounced dead on the 23rd of June 2012 at Morriston Hospital, Swansea. The deceased died from an anoxic brain injury caused by a cardiac arrest, which itself was caused by a combination of sepsis and malnourishment. There was a failure to invoke NG feeding sooner when it became apparent that the oral offering wasn't being taken by the deceased. It cannot be determined whether this would have prevented the cardiac arrest suffered by the deceased on the 15th of June 2012. 4 CIRCUMSTANCES OF THE DEATH The deceased was Catherine Jane Best and she was pronounced dead on the 23rd of June 2012 at Morriston Hospital, Swansea. The cause of death was an anoxic brain injury caused by a cardiac arrest, which itself was a combination of malnourishment and sepsis. Catherine was admitted to Morriston Hospital on the 5th of May 2012 in a malnourished 1 state after suffering abdominal pain at home. Tests carried out on the 6th of May revealed she had a duodenal ulcer and had developed sepsis. On the same date she underwent surgery for repair. The post surgical period was eventful with Catherine in and out of Intensive Care suffering from infection. Up until the 17th of May Kate was fed using a combination of nasogastric feeding and oral intake. After that date the NG feeding was removed despite poor oral intake. After being transferred onto Ward V on the 2nd of June she suffered a cardiac arrest on the 15th of June and was found unresponsive in bed. A crash team were assembled and CPR was commenced. They managed to regain circulation, however Catherine had suffered a brain injury as a result of being without oxygen. From then on the prognosis was poor and Catherine passed away on the above date after life support was withdrawn. 5 CORONER'S CONCERNS During the course of the inquest it was apparent that the deceased was a complex and challenging patient and her appetite was poor. Although there were attempts to get her to eat, and alternatives offered, her calorific input remained poor. Up until the 17th of May Catherine was fed using a combination of nasogastric feeding and oral intake. After that date regular NG feeding was removed despite poor oral intake There were instances where NG feeding were re-introduced after that date but it was not consistent and there was no explanation for the removal of regular NG feeding on the 17th of May at a time when her oral intake was not sufficient to provide the required nutrition. Whilst encouraging Catherine to obtain her calories from oral intake was appropriate there was a regular pattern of her refusing her meals or eating less than the portions provided. There was a lack of documentary evidence verifying options and encouragement although assurances that this was being done was provided by way of oral evidence. I am concerned however that in cases involving difficult or challenging patients they may not be given adequate nourishment if the oral offering is refused or partly taken. This could result in situations where a patient's ability to recover is reduced due to insufficient nourishment. 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. There was an inadequate regime of supplemented feeding by way of nasogastric tube meaning that Kate was not receiving a consistent amount of calories per day to increase the chances of fighting infection. Kate was a challenging patient and it could not be guaranteed that Kate would always take her meals thus ensuring that her calorie intake was obtained orally. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action . 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 September 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 2 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 3
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.
Bwrdd lechyd Prifysgol Bae Abertawe Swansea Bay University · Health Board 1 · gofalu am etn '1il)'dd, cydweithlo, gwella bob amser caring for each othar,·~orklng together; always Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saestieg. We welcome correspondence in Wel~h _or English. · / Date: 1 &h August 2021 Swansea Bay University ~ealth Board Headquarters One Talbot Gateway, Seaway Parade, Port Talbot SA12 7BR . PRIVATE AND CONFI.DENTIAL Mr Al.ed Gruffydd Assistant• ~roner for Swansea and Neat~ Port Talbot · The Guildhall Swansea SA14PE . Dear Sir, ' Re: The inquest into the death of Ms Catherine Best- . . As a result of thf;) inquest into the death of Ms Catherine Best held on 8th and 9th: July 2021, and the Prevention of Future Deaths Repo_rt made against the Health Board, the Nutrition and Dietetic service would like to respond and outline. the·clianges made to the relevant polici~s, proc~dures, guidance and training in· .relation to nutrition and hydration since 2012. · Governanc• Structure Within Swansea Bay .University Health .Board ·(SBUHB) the Executive Nurse· Director -has corporate responsibility for Nutrition and Hydratiqn. The governance structure is via the Hea_lth _Board Nutrition · and Hydration Steering Committee, which meets quarterly and reports to the Health Board Quality and Safety Gqvemance Gro.up which also meets quarterly. The Steering Committee has responsibility. to ensure that the relevant Health ·and Care Standard (2.5 Nutrition and Hyd_ration) are met. The Terms of Reference for Nutritiqn and Hydration Steering Committee: Pencadlys BIP Baa Abartawa, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters', Ona Talbot . Bwrdd lechyd PrlfysgolBae.Abertawe yw enw gweithredu Bwrdd lechyd Lleol F'rlfysgol Bae Abertawe Swansea Bas, University Health Boatd Is the operational name of Swansea Bay University Local Health Board . Gateway, Po~ Talbot, ~A12 7BR . . , . 2 i1 New Terms of · Reference - ~utritio I also attach the Feedback to Quality and Safety Forum/ Gqvemance Group: HBQualityand ReportforQSGG, HBQualityand Safety- Patient NutrSafety- Patient NutrNutrion update.doc . . Minimum Nutrition Standards . . The ·All-Wales Nutrition and Catering Standards for FoQd and_ Fluid Provision for Hospital lnp~tients (launched October 2011) have been· adopted within SBUHB and formed the basis of the Health Board Nutrition and Catering Policy which was published-:in M~y 2013. This replaced the previous Nutriti~n and Catering Framework -and describes the responsibilities, ·meeting structure and .governance arrangements for the organisation.. The policy is reviewed every 3 years. and is currently under. planned revie~ which is due t~ be completed September 2021. ~ @ all wales nutrition CID1222 Nutrition and catering stands Hydration and Cate, Identification of Nutritional Risk and Nutritional Care Pathway . . The All-Wales Hospitat Nutrition Care Pathway Protocol was adopted within- the predecessor organisations of SBUHe· in 2008. As part of this p~thway,. the Adult Nutrition Risk Screening Tool (WAASP) was used for the identification of nutritional risk. This tool is used for every patient on admission to ensure fhe early iden~ification and intervention for patients at risk or p~,enting with malnutrition or dehydration. The. pathway ~lso mandated the use of Al~ Wales Food and Fluid Charts which monitor /' patient's oral food and fluid intake to 'identify those patients at risk of malnutrition and to aid referral 'to specialist teams such as dietetics or speech and language therapists to identify p,oor intakes. · Audits of compliance. with the· care pathway, nutritional risk screening and the implementation of nutritional _care plans are undertaken on a monthly basis Via the Health & Care Standards Care inlUcators. Monthly Quality Assurance Matrons audits monitor if risk assessments· are completed.. The Health Board also has a programme of Quality Assurance audits which would include reviewing compliance ~ith .Nutrition and risk assessments.· Pencadlys BIP Bae Abertawa, Un Porthfa Talbot, Port Talbot, SA12 7BR / SWanaea Bay UHB Haadquai1ara, One Talbot Gatewav, Port Talbot. SA12 7BR Bwrdd lechyd Prtfysgol Baa Abertawe yw enw gwelthredu Bwrdd 1a<ihyd Lleol Prffysgol Bee Abertawe Swansea Bay University Health Board Is the openitlonal name of Swansea Bay University Local. Health Board - Link to folders 3 Docu rnentary Evidence1 (1).xlsx Safe Care2 (1).xls Patient Survey1.xlsx . . In addition. the Nutrition and Dietetic ·service undertake an annual audit of nutrition risk screening and provide feedbac·k on ·the findings to the Nutrition and Hydration Steering Committee. Local feedback .~nd action plans have been agreed to support · improvements_in nutritional care. ·In 20-19, the "All Wales iri Patient Nutrition Risk Screening Tool" was adopted within SBUHB following the Welsh Health Circular (2019) 026. The tool inclu.des additional guidance on referral to Nutrition and Dietetic Services, including for those who require enteral. tube feeding or where clinical judgm~iit indicates that there are additional nutrit1onal concerns. The implementation ·of the All Wales Tool was supported by additional training sessions provided by the Nutrition·& Dietetic Service and the launch of an e learning module. Compliarice·-with· the e learning module will be monitored through the Nutrition and -Hydration Steering Committee. · II1 lEJ ·CID494 All Wales Adult Nutritional Ri? Training including-~urse Induction . ' . The Nutrition and Dietetic Service delivers training on the id.entification of l'JU~ritional risk, nutritional care pathways and enteral tube feeding as pa,t of the New Registrant and Nurse lri~uction programmes. · ~ clinical induction of 2020 UPDATE.doc new registrants-nut · · ln addition to thee- learning module supporting the All Wal~s Nutrition Risk.S(iir:eening -Toor; there are additional e learning modules on _the use of Food and Fluid Record Chart charts. These are .mandated for-registered nursjng staff on a one off basis. Monitoring of compliance of E- reaming modules is undertaken via individual service delivery groups and is reported to the Nutrition arid Hydration Steering Committee on ~ ·ql:Jarterly basis. Each delivery ·group .will produce an action plan to support· improvements in performance. Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swar,sea Bay UHB Headquarters, Ona Talbot Gateway, Port Talbot, SA12 7BR Bwrdd lachyd Prlfysgol Bae Abertawe yw enw gwelthradu Bwrdd lachyd Llaol Pr1fysgol Baa Abartawe swa·nsaa· Bay Unlvar:sl~y Health Board Is the operational name af Swansea Bay University Local Health Board . · . · . ~ Nutrition steering C~mmitte Report.do Medical Education .. . 4 The Nutrition and Dietetic Service deliver training sessions. on nutrition and enteraV · · parenteral nutritio11 for F1 and F2 medical staff as part of their ongoing professional developme_nt. · · ManJgement of Refeedlng Syndrome and Out of Hours Enteral Feeding Regime ' ' ' The Swansea Bay University Health· Board -·Guidance on the ·Managemer:it of ·Refeeding Syndrome and the Standard Out of Hours Enteral Feeding Regime have been reviewed three yearly since they were published in 2011 .. These 2 documents were reviewed most recently in April 2020 to reflect _changes in the recom·mendation for electrolyte supplementation ·and energy provision in the National Guidance1• . @ m CID3S0 Enteral · . CID376 Guideline Feeding R~gimen foforthe Managemen The standard enteral feeding regime in critical care areas was also ·updated in 2020'. to reflect changes in clinical practice.· Adctitional SBUHB Guidance on the Nutritional Management of Patients with Eating Disorders during acute admissions and a Standard Enteral Feeding Regime for patients with ·Eating Disorders were published in June 2012. This guidance has been updated to reflect changes in the recommendations ofthe'MARSIPAN working group2 and is reviewed every· 3 years. J CID486 Nutritional Management of Pati Insertion and Management of NG Feeding tubes The Health Board policy on The Insertion and Management of NG Feeding Tubes was updated in 2018 and includes reference to the .clinical decision making process to support NG tube feeding. · ll Pancadlys BIP Baa Abartawa, Un ·Porthf■ Talbot, Port Talbot, SA12 7BR / Swan■- Bay UHB Headquarters, Ona Talbot Gateway, Port Talbot, SA12 7BR Bwrdd lechyd Pr1fysgol Bae Abertawe yw enw gwelthredu Bwrdd lechyd Ueol Pr1fysgol Bae Abertawe Swansea Bay University Health Board Is the operatlonal narne of swansea Bay University Local Heallh ~oard · .. ,, 5 A programme of competency based implementation of the updated policy.: The policy is re.viewed every 3 years . tr~1ning was delivered to support ·the . , . rn CID504 ABMU Policy for the insertion anr Additional Care Plan for the Management of High Nutrltlonal Risk during ·the .COVID 19 P•ndemic . During the COVIP 1_ 9 pandemic- a Care Plan for the Management of High· Nutrition.al Risk was implemented to support .areas in the· event of low staffing levels or staff redeploym~nt. · · · · · · · ~ CID3200 Pathway for Management of ·. The Nutrition and Dietetic service are· con~inuing to work wit_h colleagues to develop this care plan to support areas c;:,f staff shortage. · · · Nutrition and Dietetic Servi.ce Clinical Standards for In Patient Nutritl~"'al Support . . _The Clinical Stan.dards for· Inpatient Nutritional Support have been adopted by the Health Board since 2017. They inciude ~fereric_e to consideration of-enteral nutrition for patients who are unable to nieet their _nutritional requirements orally. An audit of compliance·to the stand~rds is undertaken every 2 ye~rs by the Nutrition and Dietetic Service with the next planned audit in autumn 2021 . The results and-Action Plan for improvement a·~e agreed with the Nutrition and Dietetic Service Clinical Governance meetings. · · Acute Nutrition ·support Clinical Stai I hope ·that the information contained in·the Health Board's response 'will provide you with the assurance required in relation to the Pr~vention of Future Deaths.Report that ·was receiv~d as a result of the Ms Best inquest. · j . Pencadlys BIP Bae Abertawe, Un Porthfa Talbot; Port Talbot, SA12 7BR / Swansea Bay UHB Headquartera, One Talbot Gateway, Port Talbot, SA12 7BR . Bwrdd lechyd Prlfysgol l;lae Abartawe ·yw enw gwelthradu.Bwrdd lechyd Lleol Pr1fysgol Baa Abertawa Swansea Bay University Health Board Is the operational name.of Swansea:Bay l/nl~rslty ~cal Health Board . please do not hesitate to conta_ct the Health Board if you have any queries. Yours Sincerely 6 EXECUTIVE DIRECTOR OF Tf1ERAPIES AND HEALTH SCIENCE References: 1. A Pocket Guida 1D Cllnlcal Nutrition - Fifth Edition. PEN Group Publlcatlons, British Dietetic Association . . 2. MARSIPAN Management of Really Sick PaUenl& with Anorexl,i Nervosa; (2014). Pencadlys BIP Baa Abertawe, Un Porthfl Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters, One Talbot . . Gateway, Port Talbot, SA12 7BR B)Wdd lechyd Prffysgol Baa Abartawe yw enw gwellhredu Bwrdd lechyd Uaol Pr.tfyagol Bae Abertawe Swansea Bay University H~llh Board Is the operaUon11I name of Swansea Bay University Local Health Board . · . · ,
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