Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0259, written 28 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 | 28 Jul 2021 |
|---|---|
| Reference | 2021-0259 |
| Deceased | Jacob Owczarek |
| Coroner | Dr Elizabeth Didcock |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust |
| 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Executive, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust 2. Care Quality Commission 1 CORONER I am Dr Elizabeth Didcock, Assistant Coroner, for the coroner area of Nottinghamshire 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 28th April 2020, I commenced an investigation into the death of Jacub Owczarek, aged eleven months. The investigation concluded at the end of the inquest on 30th April 2021. The conclusion of the inquest was a narrative as follows: Jacob Owczarek presented to Bassetlaw Hospital Nottinghamshire, at the age of six months, very unwell. He had pyelonephritis, a serious kidney infection. This was treated, but he did not continue on an antibiotic to reduce the risk of further urinary infection after discharge, as was necessary, as the family did not understand this was required. Follow up investigations to look for underlying abnormalities of the renal tract were performed. These scans showed obstruction of both ureters, the tubes that drain urine from both kidneys down to the bladder. The scan results were not reviewed in life, either at the time the scans were performed, nor when Jacob presented again at the age of ten months with a further kidney infection. Jacob died at age eleven months from acute pyelonephritis. He also had evidence of chronic kidney scarring and infection, with severe urinary obstruction at the time of his death. Had the scans been reviewed in life it is likely on a balance of probability that he would have had treatment to relieve the obstructions, and would not have died. His death was contributed to by Neglect. 4 CIRCUMSTANCES OF THE DEATH Jacob died from an acute kidney infection (pyelonephritis), a treatable condition. He had presented on two previous occasions unwell with sepsis from the urinary tract. The seriousness of the infection on the second presentation, was not recognised, and he was allowed home. The investigations arranged to look for underlying structural abnormalities of the renal tract were not reviewed in life, and therefore Jacob was never referred for surgical treatment to relieve his obstructed renal tract. There were systemic failings in his care, that remain in my view despite a Serious Incident Investigation undertaken, and action plan completed, by the Trust. 1 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. – 1. Continuing low compliance with the Paediatric sepsis screening tool 2. Lack of Named/Responsible Consultant review prior to a child’s discharge 3. No alert/review system for ICE results yet in place for all the Paediatric team 4. No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned) 5. The risk of continuing Login issues when Locum doctors are working at the Trust 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 29th 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. I ask that the CQC undertake a visit to the Trust after 29.9.21 to review the compliance with the Paediatric sepsis screening tool, a serious safety issue that has been highlighted by myself and the Doncaster Coroner repeatedly in PFD reports over the last 5 years. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 8 , Jacobs’ parents , GP, Newgate Medical Group 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 28th July 2021 Dr E A Didcock 2
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.
Doncaster Royal Infirmary Armthorpe Road, Doncaster South Yorkshire, DN2 5LT www.dbth.nhs.uk 28 September 2021 Dr Elizabeth Didcock Assistant Coroner for Nottinghamshire HM Coroner's Service The Council House Old Market Square Nottingham NG1 2DT Dear Dr Didcock Re: Inquest touching the death of Jacob Owczarek I write in response to the Regulation 28 report dated 28 July 2021 which was issued to the Trust following the above Inquest. I have met with the relevant teams to discuss the issues and will provide information and assurance on each. Please, may I reiterate our sincere condolences to the family of Jacob. The issues raised within the report are detailed below in bold and the response is laid out underneath. I have also included an action plan, which will be monitored by both the Children & Families and Medical Division with the oversight of the Quality and Effectiveness Committee, which is a subcommittee of the Board of Directors. The enclosed action plan includes recommendations that arise specifically out of the care and treatment provided to Jacob, as well as updated actions relating to the relevant recommendations that have previously been identified and are currently being actioned by the Trust. The inclusion of previously identified recommendations/action points is to ensure that in delivering continuous improvement, relevant learning from across the organisation is considered such that a joined up and comprehensive action plan is produced against which the identified actions can be monitored and delivered. Matters of concern: 1. Continuing low compliance with the Paediatric sepsis screening tool Compliance with the Paediatric sepsis screening tool is being monitored proactively by the Paediatric Sepsis lead, Clinical Governance Lead for Paediatrics, and the Divisional Director of Nursing for Children & Neonates with the support of the clinical audit team. Results are collated at the end of each quarter and presented in a separate part of the clinical audit and effectiveness report. The current audit tool which reflects the report shared at the inquest, reviews the clinical records of all children admitted with a clinical coding of sepsis during the relevant time period. This includes children referred via the Emergency Department (ED), General Practitioner (GP) and Community Midwife (CMW). The results of Q1 for 2021-22 demonstrate that of the 14 patients that met the audit criteria 12 patients (85.7%) had a Sepsis Screening and Action Tool completed. In the case of the 2 patients (14.3%) where this was not completed the report reflects the following comments: Comment for the patient with no sepsis screening and action tool completed for May-21: Patient brought to ED resus ASHICE cardiac arrest alert, treated immediately as sepsis, therefore sepsis screening and action tool not completed, but very clear documentation. Comment for the patient with no sepsis screening and action tool completed for June-21: Seen in ED resus and decision to treat immediately as possible for sepsis due to history, therefore sepsis screening and action tool not completed. Clear documentation in the clinical notes. Where a clinican recognsies sepsis due to the clinical presentation and commences appropriate investigations, treatment and management which is documented within the clinical records, it is acceptable that they do not retrospectively complete the Sepsis Screening and Action Tool. The method of referral for 11 patients (78.6%) was via ED, with other sources being GP, Midwives or open access. The audit results are shared at the Audit and Effectiveness Forum as well as the Specialty and Divisional Clinical Governance Committee. For enhanced monitoring, the results of the Paediatric sepsis audit are also being shared at Trust Clinical Governance and the Quality and Effectiveness Committee. In addition, the following actions have been taken within Paediatrics: • A memo was issued by the Children’s Services Matron on 21 April 2021 to all members of the paediatric medical and nursing teams outlining actions following the SI investigation, including reference to the sepsis audit results and the need to improve compliance. • The Children’s Services’ Matron shared information regarding the SI investigation, inquest outcome and completion of the Sepsis Screening and Action Tool in the July Matron Newsletter; the Newsletter is produced monthly and will continue to share messages as required around sepsis assessment and management. Whilst the Newsletter is aimed at communication between the Matron for Children’s Services and the nursing teams across the children’s clinical areas, from September 2021 the Newsletter will be noted at the monthly specialty Clinical Governance meeting and embedded within the meeting notes. This will provide an additional way in which key messages are disseminated to appropriate clinical and nursing teams. • A sepsis audit tool Task and Finish group with MDT input from both Paediatric and ED teams has been set up to review the audit tool for sepsis management, which will audit the pathway from the point of arrival in the Emergency Department. Due to the complexity of the different referral pathways this is a complex audit tool to develop, it is currently in the final stages of development, the aim is to pilot this in Q3. For Q2 the current audit tool will be used. • • The sepsis screening and action tool Standard Operating Procedure (SOP) has been reviewed in line with review date of September 2021, this is currently shared for comments and will be approved at the specialty Clinical Governance meeting in October. In addition to the audit process, the Divisional Director of Nursing for Children & Neonates and the Matron for Children’s Services have developed an assurance tool, which is being completed weekly for a period of 12 weeks, auditing approximately 5 sets of clinical records every week from each acute area. Unlike the sepsis audit the assurance tool is not exclusive to patients with a clinical diagnosis of sepsis. The tool is designed to monitor the following which were areas of concern noted at the inquest: Was the sepsis screening and action tool completed, if not is there clear evidence documented of assessment for sepsis within the clinical notes (this reflects the question in the sepsis audit) Was the sepsis screening & action tool completed correctly and who by (Nurse, Doctor, both Nurse and Doctor) If sepsis is indicated were antibiotics commenced within 1 hour/90 minutes of review Is English the first language of the family, if not were interpreter services accessed Evidence that explanation of diagnosis and management discussed with parents Consultant review prior to discharge (CHW only) Discharge checklist completed (CHW only) Ward urinalysis undertaken where clinically indicated and sent for microscopy, culture and sensitivity (MC&S) Take home medication dispensed correctly Discharge letter sent to GP and copy provided to parents Follow up appointments made as requested The reports for July and August 2021 had action plans developed specific to the results for each clinical area with the reports shared via Clinical Governance, in relation to assessment of sepsis there was 100% compliance in all areas. • A working group has been developed to evolve from ‘paper-based’ physiological observation charts to electronic observations at both Doncaster and Bassetlaw. The current Paediatric Advanced Warning Score (PAWS) charts have been shared with Nervecentre for development on the platform and the paediatric team is working closely with Nervecentre. Due to a major incident at Doncaster Royal Infirmary which has resulted in the temporary relocation of children’s inpatient services the implementation date is December 2021 which is in line with services moving into modular wards. As advised by the implementation team once the e- observations are embedded in practice, sepsis screening will then be incorporated into Nervecentre. The paper version of the sepsis screening and action tool will remain in use until that time. • Sepsis awareness training will remain on the mandatory induction programme for newly appointed staff; this specifically includes reference to the paediatric sepsis tool. Ongoing training is provided to staff within Paediatrics by way of MDT staff development days, which will continue to be delivered and include sessions provided by the Paediatric Consultant Lead for sepsis. This training which commenced in 2017, references the paediatric sepsis tool within clinical scenarios. Whilst this training was stepped down during the Covid-19 pandemic it re-commenced in April 2021 via MS Teams with monthly sessions being held since then. In view of the cause of death recorded as pyelonephritis the Divisional Director of Nursing for Children & Neonates has undertaken two audits to look at management of children under 6 months and over 6 months following discharge • when the patient has a clinical coding of urinary tract infection. The results of both audits did not identify any areas of concern when measured against the NICE Standards. In addition, the following actions have been taken within the Emergency Department: Inclusion of “Recognition & management of the sick child” which includes sepsis in junior doctors’ induction with reference to the sepsis screening and action tool. This training is aligned with the European Paediatric Advanced Life Support (EPALS) course and is delivered by the Paediatric Emergency Medicine Consultant. Teaching sessions are delivered to junior and middle grade doctors twice in a 4 month period (junior doctors rotate every 4 months) with topics involving sepsis. This teaching session includes recognition and management of sepsis by using the sepsis screening and action tool. All junior doctors, nursing staff, advanced care practitioners (ACP), trainee ACPs and consultants can access these sessions through Microsoft Teams. Simulation sessions are run on both Doncaster and Bassetlaw sites weekly with one paediatric topic monthly, the last session on paediatric sepsis was in August. These are open for all members of the MDT they are not mandatory at present, however, ED are planning to make this a core competency for all the junior doctors during their training in ED. Recruitment of a Paediatric Clinical Educator specifically for ED who works closely with the Paediatric Clinical Educators who support children’s services. The Clinical Educators support new staff on induction, which includes sepsis screening and management with reference to the sepsis screening and action tool. ED is currently undertaking work to incorporate the sepsis screening into the Symphony system used in ED, once this is completed further monitoring of compliance can be undertaken specifically for patients that present via ED. Staff training will be delivered to the MDT once this is completed prior to ‘go live’ date which is not confirmed. 2. Lack of Named/Responsible Consultant review prior to a child’s discharge All admitted paediatric patients are discussed with the consultant on service at each morning and evening handover as a routine practice across both sites, therefore, all admitted children are reviewed regularly by a Consultant during their admission. Patients referred that are deemed not to require admission following assessment by the ST4-8 Junior Doctor may be discussed with/reviewed by the Consultant of the week (COTW) where clinically indicated and if requested prior to discharge. The consultant is available for discussion of any case seen by the junior staff. The COTW does not review every child referred to the unit who does not require admission but there is a process in place to ensure that the case notes of all attendances are sent to the COTW in the preceding week for a review to ensure no cases that require follow up are missed. 3. No alert/review system for ICE results yet in place for all the Paediatric team ICE training has taken place for all Paediatric consultants to enable them to review results electronically, and the electronic ICE system is now operational within the Paediatric department. The results are added to the folder of the requesting clinician and are available for clinicians to view electronically. The paper system remains in place as a safety net. There is a list of radiological findings that are listed in the red and amber list which leads to direct contact of the requesting clinician by the radiology team to highlight the results of an investigation. This is a failsafe system which has been in place in radiology for many years. Since the inquest we have however worked closely with the radiology lead to make further recommendations about each system and what needs to be reported in the radiology report, as well as how to ensure that when a failsafe alert is generated it is brought to the attention of the relevant staff member. This has now led to more holistic reporting and has reduced the potential for fail safe alerts to be missed by staff. 4. No current system for recording a discussion about a child, in the Radiology meetings As of 1 July 2021, radiology meetings are now clinical MDTs with meeting notes taken as by a named note taker and includes arrangements for cross cover for leave. The meeting notes are emailed to the relevant consultant, specific information related to individual patients are filed in their clinical notes. 5. The risk of continuing Login issues when Locum doctors are working at the Trust There is a Trust system which has been in place for several years to ensure locum doctors have access to the relevant and necessary IT. This system was in place prior to, and at the time of Jacob’s admission to hospital. Dr , Executive Medical Director is assured that the availability of a log-in was not the issue in Jacob’s case, but the staff member, for reasons which are unclear, chose to use a colleague’s log-in details, rather than their own, which had been issued to them by the Trust in January 2014. Out of hours, HOLT locum agency and the Clinical Site Managers deal with the booking of locum doctors (for example in the case of last-minute sickness), including ensuring that they have full access to the relevant IT systems within the Trust before they commence their locum shift. The process is the same for locums who will already have an account (IT can reset the password or create new ones out of hours). Information Governance training is an annual requirement for all substantive staff. All agencies are responsible for ensuring that staff employed by them have completed all mandatory training which includes Information Governance. Holt confirms that they have a compliance team for monitoring this. As outlined above, as a result of this work and learning from this Inquest, we are updating the Trust Sepsis action plan, which will help guide the continued efforts to keep our patients safe. While this is being worked on strategically, and in more detail at present, I am more than happy to share this with you once this has been agreed and signed off. I trust this letter has addressed the concerns raised, but please do not hesitate to revert to me should there be any outstanding issues. Yours sincerely Chief Executive Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Encs
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