Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0291, written 1 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2021 |
|---|---|
| Reference | 2021-0291 |
| Deceased | John Humphries |
| Coroner | Jonathan Landau |
| Coroner area | South London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Croydon Health Services NHS 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Croydon Health Services NHS Trust 1 CORONER I am Jonathan Landau, assistant coroner for the coroner area of South London 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 30 March 2020 an investigation was commenced into the death of John Willis Humphries. The investigation concluded at the end of the inquest on 5 August 2021. The conclusion of the inquest was: “Mr Humphries died from fluid on the lungs and a lung infection caused by a range of conditions including an infection caused by catheterisation in the context of diminishing reserves to which pressure sores contributed.” CIRCUMSTANCES OF THE DEATH 4 Mr John Willis Humphries was admitted to Croydon University Hospital on 7 January 2020 from a nursing home with a two-day history of abdominal pain. Whilst in the Emergency Department, he developed the start of pressure sores. He was admitted to Fairfield 1 Ward the following day. He was assessed as being at risk of pressure sores and the plan included repositioning at 2-hourly intervals. Mr Humphries was on occasion resistant to turns. The staff did not seek advice from external professionals or from the nursing home as to how to manage that behaviour. As a result, the pressure sores deteriorated significantly during his stay in hospital. The pressure sores contributed to his lowering reserves. Whilst in hospital, he was catheterised to monitor his urine output though a decision was taken by a doctor for him to be catheterised permanently as this was thought to be a more humane way of dealing with his incontinence and immobility than incontinence pads. Mr Humphries was discharged back to the nursing home on 15 January 2020 but deteriorated and was readmitted to hospital on 15 February 2020. He developed recurrent urinary tract infections in hospital caused by his catheterisation. His diminishing reserves made him increasingly unable to respond to antibiotics and he died 11 March 2020 from pulmonary oedema and pneumonia caused by the infections and other underlying health conditions. 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 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) I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E. (2) When Mr Humphries resisted being turned, no advice was sought from external professionals or the nursing home as to how to manage the situation. The nursing home in particular had effectively employed a range of strategies to deal with the situation and would have been able to provide guidance had the staff been contacted. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 26 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 am 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. In this case, I have sent it to Mr Humphries’ daughters. 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 Jonathan Landau, HM Assistant Coroner 1 September 2021 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.
Croydon Health Services NHS Trust 1. Title: Trust Response to the Prevention of Future Deaths notification issued on the 1st September 2021 2. Vision: Strive to ensure that patients are kept free from harm, and develop a culture where there is accountability to deliver a zero tolerance for the development of pressure ulcers within Croydon Heath Services 3. Purpose: This paper outlines the Organisations actions in response to meeting the ask as set out by the Assistant Coroner on the 1st September 2021 in relation to the prevention pressure ulcers and their deterioration whilst within our care from non-concordant patients. 4.Prevention of Future Deaths Notification: There was an inquest into the death if Mr Humphries which concluded on the 5th August 2021, the conclusion of the inquest was: Mr Humphries died from fluid on the lungs and a lung infection caused by a range of conditions including an infection caused by catheterisation in the context of diminishing reserves to which pressure sores contributed Following this verdict, the following matters of concern were raised by the assistant coroner and a regulation 28 PFD report was issues for action by the Trust I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E. When Mr Humphries resisted being turned, no advice was sought from external professionals or the nursing home as to how to manage the situation. The nursing home in particular had effectively employed a range of strategies to deal with the situation and would have been able to provide guidance had the staff been contacted. 5. Response of Pressure Ulcer Reduction group: Following the receipt of the PFD the Organisations Pressure Ulcer Prevention group met on the 22nd September 2021 to discuss and review the immediate actions but in place by the Associate Director of Nursing as an immediate response to the notification. These actions and the agreed monitoring and evaluation would be a standing agenda on the monthly pressure ulcer prevention meeting for a period of at least 3 months until assurances are in place that the required improvement is imbedded within the clinical environments. There was discussion within the group that that of the required actions were in place in some of the trust clinical setting and therefore there needed to be improved communication across the adult inpatient and emergency department setting to ensure these benefits are realised by all patients and staff. 6.Agreed Actions: Although there was a particular focus in the Emergency Department and Fairfield 1 in response to this PFD the actions have been rolled out across the organisation. There were 4 high level Care and Service delivery problems identified, which have agreed actions and action owners allocated as well as a clear monitoring and reporting process. These have been agreed by the Directorate and Ward teams. These high level issues are: Croydon Health Services NHS Trust Risk of impaired skin integrity related to extended time spent in the Emergency Department lying on trollies The knowledge and skills of all staff to be improved to manage patients diagnosed with Dementia on the ward There is a need for the ward to demonstrate clear evidence that there is involvement of patients’ next of kin and any other support services in patients’ ongoing care. Communication of all the initiatives and new actions from the Pressure Ulcer prevention group to be effectively cascades to all departments The full action plan is attached as appendix 1 7. Next Steps: One of the challenges highlighted is the cascade of information across all the organisations departments, to increase awareness of the pressure ulcer initives being carried in discrete departments, such as the emergency department with quality / comfort rounding. One of the areas of focus going forwards is to ensure that there is robust and effective cascade of information from all focused groups such as Pressure Ulcer and Falls to all the clinical departments. The full action plan and paper will go to the Nursing, Midwifery, AHP and Carers Board on the 21st September 2021 and will then be discussed at the Integrated Quality Assurance Group on the 16th November 2021. 8. Appendices Appendix 1 Action Plan Appendix 2 Regulation 28: Prevention of Future Deaths Report
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