Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0265, written 9 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Aug 2021 |
|---|---|
| Reference | 2021-0265 |
| Deceased | Terence Tuttle |
| Coroner | Yvonne Blake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Norfolk and Suffolk 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 . REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive The Queen Elizabeth Hospital NHS Trust Gayton Road King’s Lynn Norfolk PE30 4ET 2 Chief Executive Norfolk and Suffolk NHS Foundation Trust 1st Floor Admin Hellesdon Hospital Drayton High Road Norwich NR6 5BE 1. CORONER I am Yvonne BLAKE, Area Coroner for the area of Norfolk 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 07/04/2021 I commenced an investigation into the death of Terence Robert TUTTLE aged 65. The investigation concluded at the end of the inquest on 29/07/2021. The medical cause of death was: 1a) 1b) 1c) 1d) 2 Frailty Syndrome Idiopathic Pulmonary Fibrosis and Schizophrenia Chronic Obstructive Pulmonary Disease The conclusion of the inquest was: Mr Terence Tuttle was admitted to hospital after testing positive for covid in January 2021. He usually resided in a care home, had known mental health illness but had been stable on anti-psychotics for many years. He was treated appropriately for acute kidney injury and pneumonia and had food and fluid record charts. Despite these demonstrating poor oral intake no prompt action was taken. It was after a review by the mental health liaison team that decisions were taken relating to nutrition and diet. Mr Tuttle had lost a significant amount of weight which contributed to his poor condition post covid. He had also been found to have a bleeding duodenal ulcer and complained about his stomach being uncomfortable. He was transferred to a different nursing home after a best interests meeting was held which decided that he had capacity to risk feed. He died 3 days later at the nursing home. 4. CIRCUMSTANCES OF THE DEATH Mr Tuttle lived and was cared for in a care home. He had a longstanding diagnosis of schizophrenia which had been stable for many years on anti-psychotic medication. In January 2021 he was admitted to a general hospital a week after testing positive for Covid-19. On admission he had an acute kidney injury which was treated, and pneumonia. He was also found to have a bleeding duodenal ulcer for which he received a blood transfusion and a proton pump inhibitor. He had been complaining of abdominal discomfort. He had diet and fluid record charts which demonstrated that he was not having adequate oral intake. Nothing was done about this and he lost 10kgs in weight over a 3- week period. He had a mental health review and was prescribed antidepressants. It appears some encouragement to take food and fluids was made but he was not seen promptly by the dieticians and he was weakened and malnourished when he was assessed. He was not felt to have capacity to refuse food initially, but this opinion was changed later. Mr Tuttle was also refusing medication including anti- psychotics. His family were refused permission to visit. They had offered to come and try to persuade him to eat. By the time he had been properly assessed he was weak after his pneumonia and lack of adequate food and fluids. His appetite was gone, and he continued to refuse food. A best interests meeting was held, and it was agreed he had capacity and could risk feed since he refused naso- gastric feeding. A new nursing home placement was found because he had increased care needs and he was transferred there approximately 50 miles away from his family who had always been involved in his care. He died 3 days later. The hospital conducted an investigation but concluded no major harm occurred to the patient due to lack of care. Their recommendations included actions which should already be in place as a matter of common sense and do not address at all the difficulties in looking after a mentally unwell patient in an acute setting. There were no prompt MH or dietician assessments. There was confusion/lack of knowledge around The Mental Capacity Act and associated paperwork. There was no focussed consistent approach to his overall care and symptoms. 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 could 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.Lack of proper dietician assessment and mental health review at an early stage. 2.Inaction when Mr Tuttle was losing weight even though his intake was recorded no-one acted upon this. 3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act. 4.Inability to care for a mentally unwell patient with physical health problems, including gastric problems, who is refusing to eat. 5.Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation. 6. Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic. 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 30 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: - Brother I have also sent it to : Care Quality Commission (CQC) Healthwatch (Norfolk) Norfolk and Waveney MIND who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9. Dated: 09 August 2021 Yvonne BLAKE Area Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH
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.
NHS Norfolk and Suffolk NHS Foundation Trust Trust Management Ms Yvonne Biake Main Administration Block Area Coroner for Norfoik Hellesdon Hospital Norfolk Coroner Service Drayton High Road County Hail Norwich Martineau Lane NR6 SBE Norwich NRT 20H Pe 16 August 2021 Dear Ms Blake Re; Regulation 28 notification regarding the care of Terrence Tuttle | write in response to your letter dated 9” August 2021 outlining your concerns regarding the care and treatment of Terrence whilst an inpatient at the Queen Elizabeth Hospital in Kings Lynn | am very sorry to hear about the sad death of Terrence. Should this letter be shared with his family, | would like to pass on my condolences to them. Having reviewed the notification | am surprised this has come to our Trust | have discussed this with colleagues at the Queen Elizabeth Hospital (QEH) to ensure we do not duplicate responses. It is regretable that we were not asked to provide information on the concern prior to the conclusion of the inquest. as | understand it we were advised that we were not an interested party. | arn confident that we would have been able to satisfy your concern immediately given the opportunity Out of the concerns listed below | would advise that NSFT are able to respond to the second part, in italics, of the first point only, The other points would be for the QEH to respond to 1. Lack of proper dietician assessment and mental health review at an early stage 2. Inaction when Mr Tuttle was losing weight even though his intake was recorded. no-one acted upon this 3, Ability to assess Mr Tuttle adequately under the Mental Capacity Act 4. Inability to care for a mentally unwell patient with physical health problems, including gastric problems, who is refusing to eat. 5. Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation 6. Apparent lack of recognition that senous harm did occur for this patient who was described as appearing cachexic it may be helpful to outline the role of the Menta! Health Liaison Teams within our acute general hospitals. The team are a triage assessment team and do not provide direct ‘hands on’ care specifically in relation to physical interventions, for example dietry advice or nutritional balance activities. The team will advise on mental iliness symptoms, diagnosis, compassionate least restrictive care and de-escalation techniques. The team will provide both nursing and medical input in relation to treatment including psychotropic medication nd monitoring whilst the patient is on the acute ward. They may also arrange for transfer to a mental health ward once the patient is physically fit for discharge but requires further support in relation to their mental wellbeing Where a capacity assessment is required for a decision on a physical health issue or intervention, the team may assist in respect of mental illness symptomology and the potential impact on a persons capacity However the decision maker will be the physical health expert. In Terrence’s notes | can see clear and regular communication between the ward and the Liaison Team, approximately two weeks post his admission the team were asked and attended the ward to assess Terrence. He was not able to participate in this but the ward reported that he had been non-compliant with his anti-psychotic medication for approximately one week. Although non-compliant, Terrence was not displaying signs or reporting symptoms of psychosis. The Liaison Team discussed this with the team Consultant Psychiatrist who advised to stop the medication due to the time lapse, concentrate on improving his physical state and re-assess. If the medication was reinstated this would require invasive monitoring procedures. These measures were with the caveat that if he deteriorated mentally to consider a Mental Health Act assessment for detention, The ward contacted the team again on 1* March as Terrence had improved physically although still refusing food and fluids. He was seen on 2 March. the team concurred he was depressed and an anti-depressent was commenced. Terrence was discussed within the daily team meeting and reviewed face to face regularly. Terrence was commenced on Amisulpride oral liquid to treat any emerging psychotic symptoms and was compliant with both medications. The team noted an improvement in mental wellbeing on 10" March albeit he continued to refuse food and fluids. Terrence was further reviewed in respect of his medications and presentation by a Consultant Psychaitrist on 11" March. The team attended a best interests meeting on 12” March where the proposal was to move Terrence to a new nursing home which could cater for his enhanced needs. The community mental health care co-ordinator kept in contact with the ward and the social worker, the plan being that once discharged the Community Mental Health Team would review Terrence in his new accomodation. | hope that this information satifies your concern. Yours sincerely Interim Chief Executive
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