Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0424, written 21 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2021 |
|---|---|
| Reference | 2021-0424 |
| Deceased | Eva Wheeler |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
##DW<<ALLTRIM(cSignedBy)>> ##DW<<ALLTRIM(cSignedByTitle)>> for ##DW<<ALLTRIM(cJurisdiction)>> REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: the Chief Executive of Cwm Taf Morgannwg University Health Board. CORONER 1 I am Rachel Knight Assistant Coroner for South Wales Central 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 24/02/2020 I commenced an investigation into the death of Eva Eileen WHEELER. The investigation concluded at the end of the inquest 15th December 2021. I made a determination at inquest that the death should be recorded in a narrative conclusion. The medical cause of death I recorded as: 1(a) Abdominal Perforation 1(b) Sigmoid Volvulus II Asthma, Ischaemic Heart Disease 4 CIRCUMSTANCES OF THE DEATH Eva Eileen Wheeler was aged 82 and was an inpatient at Ysbyty Cwm Cynon, for rehabilitation following a soft tissue hip injury. She suddenly developed a bowel obstruction which led to a perforation and died on 17th February 2020. NARRATIVE: Mrs Wheeler developed sigmoid volvulus in the early hours of 17 th February, and despite appropriate treatment and diagnosis the same morning, she was not transferred to Prince Charles Hospital for further assessment and care by surgeons. A communication error between staff meant that an emergency ambulance was not called for Mrs Wheeler, and YCC had reached the ceiling of care it could offer her. This failure is unlikely to have changed the outcome for Mrs Wheeler, as her age and co - morbidities meant that she was not a candidate for emergency bowel surgery. She deteriorated rapidly on the ward, and died of an abdominal perforation at around 16:30. 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 communication error between staff led to a failure to contact an emergency ambulance to transfer a critically ill patient to a major hospital. Since this incident, computerisation has largely replaced written notes in this Trust, and evidence from staff did not satisfy me that any changes were ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> embedded on the ground. I am concerned that there is not a clear and robust process in place for documenting, requesting and chasing-up emergency ambulances throughout YCC; (2) A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth; and (3) The on-call Medical Registrar at Prince Charles Hospital was contacted for advice, since doctors do not work at YCC overnight. Had the on-call Surgical Registrar been consulted, there may have been an earlier diagnosis of suspected sigmoid volvulus. Bowel obstructions are relatively common in an elderly patient cohort, so I question whether provision for joint discussion between the registrars should be built into a protocol. 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 15th February 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the time table 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: Family of Eva Wheeler Chief Executive of Cwm Taf Morgannwg UHB 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 21/12/2021 Signature Rachel Knight Assistant Coroner South Wales Central ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>>
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.
Your ref/eich cyf: Our ref/ein cyf: Date/Dyddiad: Tel/ffôn: Email/ebost: Dept/adran: 15 February 2022 Chair and Chief Executive Private and Confidential Ms Rachel Knight Her Majesty’s Assistant Coroner Coroner’s Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Dear Ms Knight Regulation 28 – Eva Eileen Wheeler Thank you for the correspondence in relation to the above Regulation 28 which was received by the Health Board on 23rd December 2021. Please be assured that the Health Board has taken this matter extremely seriously and action is being taken to address the matters highlighted during the inquest and those raised by yourself and the Regulation 28 report. We sincerely apologise to Mrs Wheeler’s family and would like to confirm that we have acted as directed by your findings. The details provided below align with the numerical order in which you presented your concerns. The communication error between staff led to a failure to contact an emergency ambulance to transfer a critically ill patient to a major hospital. Since this incident, computerisation has largely replaced written notes in this Trust, and evidence from staff did not satisfy me that any changes were embedded on the ground. I am concerned that there is not a clear and robust process in place for documenting, requesting and chasing-up emergency ambulances throughout YCC. Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the health board in Welsh or English. We will respond accordingly and this will not delay the response. Cyfeiriad Dychwelyd/Return Address: Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg, Pencadlys, Parc Navigation, Abercynon, CF45 4SN Cwm Taf Morgannwg University Health Board, Headquarters, Navigation Park, Abercynon, CF45 4SN Bwrdd lechyd Prifysgol Cwm Taf Morgannwg yw enw gweithredol Bwrdd lechyd Lleol Prifysgol Cwm Taf Morgannwg lCwm Taf Morgannwg University Health Board is the operational name of the Cwm Taf Morgannwg University Local Health Board With regards to the first matter, the existing process for the “Transfer of an Acutely Unwell Patient” has been reviewed and revised with a view to:- ➢ Making explicit the role and responsibilities of both nursing and medical staff. ➢ Providing further clarification regarding the separate stages of the process. ➢ Reinforcing the need for verbal instructions and discussions to be recorded in the medical records and digital nursing records. Additionally, a programme of re-education is in the process of being taken forward to ensure that all Registered Nursing staff and Medical staff are fully conversant with the revised process. Paper copies of the revised process will also be laminated and displayed by the nurses station for ease of reference at all times. Furthermore, staff knowledge and understanding of the process will be monitored by undertaking an audit following completion of the re-education process. This will be undertaken by the Senior Nurse with responsibility for the wards within Ysbyty Cwm Cynon. A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth. With regards to the second matter, the existing process has been reviewed and revised with a view to making explicit:- ➢ the need to communicate verbal medical instructions clearly and in a timely manner to the Registered Nurse with responsibility for the patient. ➢ the need to record a “nil by mouth” instruction within the medical records. This should be completed by the Doctor in keeping with best practice. ➢ the need for the Registered Nurse with responsibility for the patient to record the medical instruction “nil by mouth” within the digital nursing records in keeping with best practice. ➢ the need for the Registered Nurse with responsibility for the patient to notify all relevant staff of the need to maintain the patient nil by mouth in a timely manner. The on-call Medical Registrar at Prince Charles Hospital was contacted for advice, since doctors do not work at YCC overnight. Had the on-call Surgical Registrar been consulted, there may have been an earlier diagnosis of suspected sigmoid volvulus. Bowel obstructions are relatively common in an elderly patient cohort, so I question whether provision for joint discussion between the registrars should be built into a protocol. Nursing, Medical and Patient Safety Lead Officers met on the 14th January 2022 to discuss and explore the requirement for joint discussions as advised above. The existing process for reviewing and monitoring an acutely unwell patient is embedded across all four wards, this being the National Early Warning Score (NEWS). Where a patient’s observations are outside of normal parameters or where there are signs of physiological deterioration, Registered Nursing staff take appropriate action by seeking advice and support from medical staff. Additionally, there is an ongoing monthly NEWS audit in place to ensure compliance with the NEWS documentation, the results of which are reported and acted upon by the site based Advanced Nurse Practitioner in partnership with the Senior Nurse and Ward Managers. This includes the provision of one to one learning and strengthen clinical practice development sessions to aid competencies. During out of hours, this process continues and where it is identified that a patient is deteriorating, the escalation process is initiated. Again this processed is embedded across all four wards with all Registered Nurses being fully conversant with the action they are required to undertake, namely refer to the on call medical teams for further advice. In this case, the Registered Nurse with responsibility for the patient followed due process by referring to the medical team on call. The decision as to whether discussion or referral to another specialty is required is a clinical decision made by the on call team taking the call. Having reviewed the process which currently exists between the on call teams, there have been no reported incidents in relation this well-established process and it is therefore concluded that there is no requirement for an “on call shared discussion protocol” to be developed. Yours sincerely Prif Weithredwr/Chief Executive
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