Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0278, written 23 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 | 23 Aug 2021 |
|---|---|
| Reference | 2021-0278 |
| Deceased | Norma Rushworth |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Greater Manchester health &
Social Care Partnership and NHS England.
1 CORONER
I am Alison Mutch , Senior Coroner, for the Coroner Area of Greater
Manchester South
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 14th October 2020 I commenced an investigation into the death of
Norma Rushworth. The investigation concluded on the 13th May 2021 and
the conclusion was one of Narrative: Died from complications of
emergency surgery following a previous surgical procedure that had
resulted in an abdominal dehiscence due in part to a wound infection not
identified prior to the abdominal dehiscence.
The medical cause of death was 1a Bronchopneumonia 1b
Immobilisation following surgery for Diverticulitis 1c II Ischaemic Heart
Disease, Aortic Valve Disease, Hypertensive disease
4 CIRCUMSTANCES OF THE DEATH
Norma Rushworth was identified to have a narrowing of the sigmoid due
to diverticulitis. She was operated on at Tameside General Hospital
initially laparoscopically but then that was not viable through open
surgery. The colon was resectioned. She was discharged home. Whilst at
home she had an abdominal dehiscence and was admitted back to
Tameside General Hospital where she was operated on as an
emergency. The dehiscence had occurred as a result of an unidentified
infection of the wound, her age and cardio vascular compromise. She
developed a chest infection. She had a cardiac arrest when the central
line was removed. She was resuscitated and transferred back to the
Intensive Care Unit. She continued to deteriorate. On 10th October 2020
she died at Tameside General Hospital. Post mortem examination found
she had died from bronchopneumonia with significant underlying heart
disease contributing to her death.
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. The inquest heard that due to the pandemic and restrictions Mrs
Rushworth was not supported as she would usually have been at
outpatient appointments. The inquest heard that this impacted
significantly on the quality of the history available to clinicians;
support for a vulnerable patient and her decision making.
2. The inquest heard that following her discharge back into the
community after surgery support and monitoring was limited
notwithstanding how vulnerable she was; the complexity of her
surgery and the risk she presented. Advice re management of a
patient such as her in the community and risks and management
of them was not conveyed clearly to community health
professionals and to her family. Covid restrictions meant that
communication had been difficult, and the written documentation
did not cover the challenges this caused. Her deteriorating health
in the community was not as a result recognised at an early stage.
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 18th October 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
2
Interested Persons namely
who may find it useful or of interest.
(family of the deceased),
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 23rd August 2021
Alison Mutch
HM Senior Coroner Greater Manchester South
3
2 responses 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.
Greater Manchester Health and Social Care Partnership
4th Floor
3 Piccadilly Place
London Road
Manchester M1 3BN
T:
E:
Date: 15 October 2021
Ms A Mutch
HM Senior Coroner
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Ms Mutch
Re: Regulation 28 Report to Prevent Future Deaths – Norma Rushworth
10/10/20
Thank you for your Regulation 28 Report dated 23/08/21 concerning the sad death
of Norma Rushworth on 10/10/20. Firstly, I would like to express my deep
condolences to Norma Rushworth’s family.
The inquest concluded that Norma’s death was a result of 1a Bronchopneumonia, 1b
Immobilisation following surgery for Diverticulitis, 1c II Ischaemic Heart Disease,
Aortic Valve Disease, Hypertensive disease.
Following the inquest you raised concerns in your Regulation 28 Report to Greater
Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future
deaths will occur unless action is taken.
This letter addresses the issues that fall within the remit of GMHSCP and how we
can share the learning from this case.
Point 1 – support for vulnerable patients at appointments during the pandemic.
At the time of Mrs Rushworth’s death, hospital trusts were constrained by the
national guidance around attendance at hospital settings “Visiting healthcare settings
during COVID-19 pandemic.” The guidance restricted patients from attending
appointments with a person to support them. In March 2021 this guidance was
updated to advise that patients attending outpatients, diagnostic service and
Emergency Departments are now allowed to be accompanied by one person to
support them with making complex/difficult decisions. A link to the full guidance is
included below for information:
Coronavirus » Visiting healthcare inpatient settings during the COVID-19 pandemic
(england.nhs.uk)
Point 2. Communication between acute and community settings on risk and
patient management.
Mrs Rushworth was discharged from the acute trust on 9th September following good
post-operative recovery. District nurses attended Mrs Rushworth the day after her
discharge from the acute trust. They then attended on 3 additional days, with the
final attendance being to remove her stitches on 16th September, with this date being
scheduled by the consultant.
Mrs Rushworth’s attended A&E on the 17th September after the wound reopened.
Actions taken or being taken to prevent reoccurrence across Greater
Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board.
This meeting is attended by commissioners, including commissioners of
specialist services, regulators, Healthwatch and NICE.
2. Communication to all relevant providers to share appropriate advice and
guidance and increase staff awareness regarding the range of materials that
are already available.
3. Shared learning from this and similar cases at Greater Manchester and
borough level will be cascaded to professionals through relevant governance
and learning forums.
In conclusion, key learning points and recommendations will be monitored to ensure
they are embedded within practice. GMHSCP is committed to improving outcomes
for the population of Greater Manchester.
I hope this response provides the relevant assurances you require. Thank you for
bringing these important patient safety issues to my attention and please do not
hesitate to contact me should you need any further information.
Yours sincerely
Chair of GM Medical Executive, GMHSCP
Alison Mutch HM Coroner South Manchester Coroners Court 1 Mount Tabor Street Stockport SK1 3AG National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 16th June 2022 Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Norma Rushworth 14th October 2020 Thank you for your Regulation 28 Report dated 13th May 2021 concerning the death of Norma Rushworth on 14th October 2020. Firstly, I would like to express my deep condolences to Norma Rushworth’s family. Please accept our apologies for the length of time this response has taken to complete. The regulation 28 report concludes Norma Rushworth’s death was a result of complications of emergency surgery following a previous surgical procedure that had resulted in an abdominal dehiscence due in part to a wound infection not identified prior to the abdominal dehiscence. With the medical cause of death as result of 1a Bronchopneumonia 1b Immobilisation following surgery for Diverticulitis 1c II Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive Disease. Following the inquest you raised concerns in your Regulation 28 Report to NHS England. The matters of concern are as follows: 1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making. NHS England and NHS Improvement 2. The inquest heard that following her discharge back into the community after surgery, support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly enough to the community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result, recognised at an early stage. In response to the first query I refer to the Greater Manchester Health and Social Care Partnership (GMHCSP) response which stated that at the time of Mrs Rushworth’s death, the national guidance around attendance at hospital settings “Visiting healthcare settings during COVID-19 pandemic” restricted patients from attending appointments with a person to support them. In March 2021 this guidance was updated to advise that patients attending outpatients, diagnostic service and Emergency Departments are now allowed to be accompanied by one person to support them with making complex/difficult decisions. A link to the full guidance is included for information: Coronavirus » Visiting healthcare inpatient settings during the COVID-19 pandemic (england.nhs.uk). The visiting guidance was reviewed regularly during the pandemic. With regards the second matter of concern In terms of national discharge policy in place in October 2020, this included a clear set of agreed criteria to reside, which provide a framework to guide clinical staff as to whether a person is fit to be discharged or should remain in hospital for further treatment. The guidance advises that patients are reviewed against these criteria on a daily basis. The guidance also provided information on how health and social care staff should engage with patients and carers ahead of discharge. Section 6 of the current version of the guidance summarises the actions and support that should be provided. Hospital discharge service guidance - GOV.UK (www.gov.uk) As the cause of death documented in the report also refers to wound infection, we would also like to highlight to you that in 2018 NHSEI commissioned The National Wound Care Strategy Programme, a long-term commitment to improving wound care. The aim of the England-wide strategy is to improve the quality of chronic wound care through innovative solutions that will improve wound healing and prevent harm in line with the commitments set out in the NHS Long Term Plan. The Programme aims to standardise wound care by developing clinical recommendations which support excellence in preventing, assessing, and treating people with wounds to optimise healing and minimise the burden of wounds for patients, carers and health and care providers. The recommendations of the National Wound Care Strategy Programme are available online and have been widely publicised to the clinical community. In addition, the Programme and Health Education England (HEE) have published free to access, online education on a number of wound care topics, and continue to develop further wound care education resources. These resources are aimed primarily at registered clinicians and experienced health and care support staff but the NWCSP is also contributing to the work of the NHS England and Improvement Enhancing Health in Care Homes team which is developing similar resources for novice health and care support staff. Work is also underway to support Higher Education Institutions that provide pre-registration clinical education in providing wound care education of an appropriate standard and range in their pre-registration programmes. The learning from the PFD has been shared with all NHS England and Improvement regions. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director
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