Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0345, written 15 Oct 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 Oct 2021 |
|---|---|
| Reference | 2021-0345 |
| Deceased | Harbans Singh |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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: Prevention of Future Deaths Report Mr Harbans SINGH (died 27 April 2021) THIS REPORT IS BEING SENT TO: 1. Chief Executive at Warwick Hospital 1. CORONER I am: Sean McGovern, Senior Coroner for Warwickshire, Warwick Justice Centre, Newbold Terrace, Royal Leamington Spa. 2. CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3. INVESTIGATION and INQUEST On 25th August 2021, I commenced an investigation into the death of Mr Singh (aged 85 years). The investigation concluded at the end the inquest on 15th October 2021 at Warwick Coroners Court. 4. CIRCUMSTANCES OF THE DEATH Mr Singh was an inpatient at Warwick Hospital from 2 November 2019 to 14 January 2020. Whilst in hospital he was newly diagnosed with hypothyroidism and prescribed Thyroxine. On discharge from hospital neither the new diagnosis nor the medication were included in his discharge summary. The back-up system regarding discharge also failed so his new diagnosis and medication were not documented. Mr Singh subsequently attended the hospital and had thyroid blood tests on 13.08.20 and 9.04.21 both demonstrating significant hypothyroidism. On neither occasion were the results highlighted as significant and appropriate medication was not prescribed. On 23rd April 2021, Mr Singh was admitted to Warwick Hospital with symptoms of hypothyroidism and diagnosed with severe hypothyroidism. He died the following day. Mr Singh died of natural causes in the context of neglect as set out above. 5. CORONER’S CONCERNS During the inquest, the evidence and information 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: i. ii. During the inquest it was accepted there was a system failure regarding the discharge process and I am concerned that such a situation will not re-occur. I am concerned that the thyroid blood tests in August 2020 and April 2121 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. 6. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 10th December 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 following: 1. HHJ Teague QC the Chief Coroner of England & Wales Chief Coroner's Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk 2. Mr Singh’s family – 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. Date: 15th October 2021
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.
Chief Executive Warwick Hospital Lakin Road Warwick CV34 5BW 2 December 2021 Senior Coroner S McGovern Warwickshire Justice Centre Newbold Terrace Leamington Spa Warwickshire CV32 4EL Dear Mr McGovern Thank you for your Regulation 28 Report, dated 15 October 2021, relating to the inquest of Mr Harbans Singh. I was sorry to read of your outstanding concerns at the conclusion of the inquest and hope that the following information will provide you with further reassurance. Following receipt of your report, the Trust convened a Working Group to review and critically reappraise the systems and processes involved in Mr Singh’s care. This Group was chaired by the Trust’s Director of Nursing and included management leads from Pharmacy, IT, Business Change, and the Trust’s Patient Safety Manager. Please note, the following text mentions various Trust IT systems, and, for ease of reference, a glossary has been provided at the end of this letter briefly describing each system. The working group explored, and reflected upon, a number of points relating to Mr Singh’s care, including the adequacy of the actions arising from the Trust’s Root Cause Analysis (RCA) investigation, and sought to address the specific matters of concern raised in your Regulation 28 Report. Namely: 1. 2. During the inquest it was accepted there was a system failure regarding the discharge process, and I am concerned that such a situation will not re-occur. I am concerned that the thyroid blood tests in August 2020 and April 2021 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. 1. System failure regarding the discharge process Historically discharge summaries for patients being discharged from in-patient areas were prepared on the electronic patient record system, Lorenzo, and a hard-copy was printed off and sent by post to relevant parties (eg GP practices). The Trust has, over the last 5 years, been rolling out an electronic discharge summary process whereby an electronic version of the final discharge summary was sent to the GP from Lorenzo. This was a complex project, The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. involving building links with IT systems across multiple GP practices. At the time of Mr Singh’s original discharge, the Trust still had a dual process of creating discharge summaries, whereby some were paper, and some were electronic. Shortly before his discharge, Mr Singh was moved from the ward where he had been treated to a Surge Capacity ward. This had been opened shortly before to help provide additional temporary capacity in a time of high demand. Mr Singh had been identified as a suitable patient for transfer as his medical episode was complete and he was awaiting discharge. The staff member dealing with Mr Singh’s discharge had been transferred on a temporary basis to that ward from an area which still used the legacy (paper) system for discharge summaries. They used a paper copy of a draft discharge summary when checking his TTO (take home) medication. This did not include new medication started during Mr Singh’s admission. The discharge summary was subsequently amended on Lorenzo to include this omitted medication however the staff member was not aware of the need to finalise the discharge summary on Lorenzo to ensure that a copy was sent electronically to the GP. This meant that the GP was not made aware of new medication started during Mr Singh’s admission and this did not appear on the copy of the discharge summary within the e-record available to staff caring for Mr Singh on future admissions. A back up system, CESIL, is in place to send alerts for any patients who were discharged from Lorenzo where discharge summaries had not been finalised, however the review identified that the CESIL alert was not seen by the temporary staff on the Surge Capacity ward. As highlighted in the Trust’s root cause analysis report, and in the evidence given at the inquest, the process of using paper discharge summaries no longer exists at the Trust and TTOs are now all prepared from the electronic system, meaning this error could no longer occur. A Patient Safety Newsletter was sent out to all staff in July 2021 relating to this topic. In the section titled “working safety with EPMA” the requirements for completing electronic discharge summaries is highlighted. Additionally, more detail is given on the process further down in the section titled “Reminder: Lorenzo-complete discharge summary”. The Newsletter is included as an appendix to this letter for reference. 2. Thyroid blood tests in August 2020 and April 2021 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. In relation to ‘flagging’ of hypothyroidism results to clinical staff, the Trust wrote to the Coventry and Warwickshire Pathology Network in June asking if a supressed thyroxine blood result could be ‘flagged’ to the requesting clinician. The response was that it could not, as this is not recommended by the Royal College of Pathologists. A number of staff within our senior consultant team have also considered this option and agree that asking the laboratory to flag (by flag we mean directly contact-usually by telephone) with the clinical team every time a low or suppressed thyroxine level came in would not be beneficial. Thyroxine results are received frequently and so it would cause significant resource implications for the laboratory, allied to which it is recognised that most such results do not require urgent action and indeed can often be a transient response to a separate existing condition. The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Whilst recognising that ‘flagging’ results to clinical staff by the laboratory is neither recommended or proportionate, it is vitally important that blood results are seen, acknowledged and acted upon. Earlier this year a service improvement piece of work around results management was undertaken by the Digital Transformation Team and a report produced in May 2021. The two key recommended deliverables from the report were: • Review the current use of electronic systems in terms of results acknowledgement and other associated processes • Develop a Trust wide policy for results acknowledgement and associated processes As a result of the recommendations from the service improvement report a Clinical Steering Group was set up with representation from clinicians, Pathology, Radiology, the Cardiac Investigations Unit, and the Digital Transformation Team. The initial remit of the Clinical Steering Group was to: • Develop a Trust wide policy in relation to results requesting and acknowledgement • Ensure that a clinically led decision is made in terms of the system(s) to use for requesting, reporting, and acknowledging of results Demonstrations by various suppliers of potential systems were provided to the Clinical Steering Group between July and October 2021 and a decision was made in terms of the most appropriate systems to use. These systems will be used until the new Electronic Patient Record system is in place, which is estimated to be from 2023/2024 onwards. A draft policy has been created and circulated to the Clinical Steering Group and initial feedback has been incorporated. The draft policy takes into account requesting, reporting, reviewing, acknowledging, actioning and escalation of results and also includes roles and responsibilities and monitoring compliance with the policy. This policy will be further developed as the project progresses and clinical systems are implemented. In addition, a project team has been setup to review existing technical and operational issues, develop a set of Standard Operation Procedures, and ultimately progress implementation of the clinical system(s) related to results and their reporting. A project plan has been developed by the project team with a summary as below: • Phase 1a: Acknowledgement of Pathology and Radiology results in Inpatients and the Emergency Department • Phase 1b: Pathology and Radiology requests and results in Inpatients and the Emergency Department • Phase 2: Requesting, results and Acknowledgement in Outpatients Key project milestones are: • 25/02/2022 - Stage 1 Complete - Review and development of Standard Operating Procedures, review of systems, review and resolution of technical and operational Issues • 01/04/2022 – Stage 2 Complete – End to End Testing of systems and processes, pilot with selected specialities and business process validation/user acceptance testing The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. • 29/07/2022 – Stage 3 Complete – Go Live preparation, Go Live and post Go Live support • 08/04/2022 – Publish Trust Policy in preparation for systems go live • 30/05/2022 – Go Live with results acknowledgement in Inpatients and the Emergency Department • 27/06/2022 – Go Live with results acknowledgement in Outpatients • 14/09/2022 – Stage 4 Complete – Project review, lessons learnt and project closure 3. Whilst the Trust has responded above to the two direct concerns within your regulation 28 report, we have also reflected on whether we could further improve care to our patients around these themes. As a result, the Trust has since actioned, or agreed to action, the following: 1. The Trust will consider more robust methods of training and supporting our temporary staff in Surge Capacity Areas1. The Director of Nursing has directed the Staff Bank Manager within the corporate nursing team to lead on a piece of work to review and amend as necessary the temporary staff induction and training pack including specific guidance regarding the Discharge Summary process. 2. IT support officers are now available to support staff in Surge Capacity Areas. The Working Group identified two wards as needing immediate support, and this was arranged with immediate effect. 3. A Safety Practice Alert (copy included as an appendix to this letter) was issued to all staff on 9 November 2021 reiterating the importance of ensuring discharge information is correctly entered onto relevant IT systems. As with all Safety Practice Alerts, this was circulated to all staff electronically via the Trust’s weekly newsletter and requires ward/department/team leaders to read out and discuss the Alert at every ward handover for two weeks after issue. Of note these alerts are now also sent to our temporary workforce staff. 4. Changes will be made to DIGIT to alert staff to any incomplete fields that require completion to ensure appropriate communication with the patient’s GP. Testing of this is now underway and will be rolled out across the Trust by April 2022. Thereafter compliance audits will roll out until use of the fields is normalised. Although our original RCA Investigation highlighted a number of care management concerns which have now been addressed, I am grateful that your Regulation 28 Report provided us with a further opportunity to consider and improve our care. 1Wards opened when patient volumes challenge or exceed a hospital's servicing capacity. The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. I hope that this provides you with the assurances that you require but if you have any outstanding concerns, please do not hesitate to contact me. Yours sincerely Chief Executive The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. Glossary of Terms Used DIGIT is the Trust’s Capacity (bed) management system. DIGIT gives the capacity management team a quick overview of the wards which have empty beds. DIGIT is used to track a patient’s infection status to ensure the patient is on the correct ward and is also used to track when patients are ready to be discharged home, or if there are delays to discharge. EPMA is the electronic prescribing and medication administration module within Lorenzo. EPMA allows staff to prescribe drugs and, for inpatients, allows staff to record drugs administration (when drugs were given, if they were refused, what dose of drug was given etc.) Lorenzo is the Trust’s Patient Administration System and Electronic Paper Record. The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process.
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