Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0042, written 10 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2022 |
|---|---|
| Reference | 2022-0042 |
| Deceased | Sheila Steggles |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Norfolk & Suffolk NHS Foundation Trust Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE 1 CORONER I am Yvonne Blake Area Coroner for the coroner 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 15th November 2019 I commenced an investigation into the death of Sheila Elizabeth STEGGLES aged 72. The investigation concluded at the end of the inquest on 4th February 2022. The cause of death was 1a) Acute Pulmonary Embolus (PE) 1b) Deep Vein Thrombosis (DVT) The conclusion from the jury was Natural Causes. There were a number of collective failings and missed opportunities that may have contributed to Shelia Steggles’ death. 1) There was no written Venous Thrombus Embolism (VTE) assessment for Sheila Steggles after July 2019. 2) Insufficient consideration was given to Sheila Steggles’ reduced mobility because of diagnostic overshadowing. 3) The clinical notes failed to highlight Sheila Steggles’ past medical history of Deep Vein Thrombosis (DVT) and associated risks. 4) There was inadequate DVT training for ward staff. 5) Administering a prophylactic dose of heparin may have resulted in a different outcome. 4 CIRCUMSTANCES OF THE DEATH Sheila Steggles was admitted twice under section of the Mental Health Act in 2019. She had a diagnosis of Bi-polar Affective Disorder and suffered from depression and anxiety together with Hypothyroidism and 2 previous DVT’s. She had Chronic Lymphoedema to both legs. In October 2019 Sheila Steggles was transferred to a rehabilitation ward to ready her for discharge to supported housing prior to going to her home, as it was felt that her Regulation 28 – After Inquest Document Template Updated 30/07/2021 presentation and mental health had improved. She was usually independently mobile but on 25th and 26th October 2019 she requested a wheelchair and one was brought in from home. She used this to push and walk about the ward. By 31st October 2019 when Sheila Steggles complained of feeling unwell her mobility had declined and she was not coming out of her room. There was no evidence that she was walking then except briefly when seen by a doctor. No specific illness was detected although physical observation and blood tests were done, these were all normal. The same doctor saw her on 1st November 2019 again nothing specific was found. On both occasions Shelia Steggles was examined for a current DVT but no documented formal assessment of her future risk of DVT was made. She had several risk factors, she was over 60, obese and had a past history of DVT. Her reducing mobility was not considered a further risk factor even though it put her into the very high category because it was thought to be due to her mental health and may therefore improve. After the 1st November 2019 the doctor went on leave and left instruction that any further concerns be raised and if needed a doctor would review. Sheila Steggles was not reviewed on 2nd November 2019 and remained on her bed in her room and on 3rd November 2019 another doctor reviewed her, again looking for current DVT but finding none and no consideration was given to her future risk given that her mobility was greatly reduced. On 4th November 2019 a doctor was called for general not specific concerns and he chose not to examine Shelia Steggles since on the notes her presentation had not changed from 3rd November 2019. On the morning of 5th November Sheila Steggles collapsed whilst being moved and suffered a cardiac arrest. Resuscitation was prompt and emergency services attended but she died in the ambulance. An expert opinion concluded that on the balance of probabilities the DVT was not formed before the 2nd November 2019 and that prophylaxis given then would have prevented the DVT and the PE. 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: Irrespective of the reason for a person’s mobility reducing, if it does so and this is a known risk factor then notice must be taken of it and appropriate steps taken. Medical staff should follow the Trust’s protocols and perform and document a VTE risk assessment when the reduction in mobility is reduced (from their baseline) even if it is not known if/ how long the reduction will continue. All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts. If a patient is to be reviewed then a specific plan should be placed on to the care plan so that everyone knows what is needed to be done. All staff should be aware of a patient’s relevant past medical history. Junior staff should consult more senior staff if they are unsure of the effect that anti- coagulation will have on anti-psychotics or other medication and are thus concerned about administering this. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE Regulation 28 – After Inquest Document Template Updated 30/07/2021 You are under a duty to respond to this report within 56 days of the date of this report, namely by April 04, 2022. 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 (family of Sheila Steggles) G.T. Stewart – Solicitors for family – Counsel for family and Department of Health Care Quality Commission HSIB Healthwatch Norfolk 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 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 by the Chief Coroner. 9 Dated: 10/02/2022 Yvonne BLAKE Area Coroner for Norfolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
NHS Norfolk and Suffolk NHS Foundation Trust Trust Management Ms Yvonne Blake Helnedon tteepie Norfolk Coroner's Service Drayton High Road County Hal Hellesdon Martineau Lane Norwich Norwich NR6 SBE NR1 2DH Date: 22 March 2022 Dear Ms Blake | write in respect of Sheila Steggles who died on 5" November 2019. On 10” February 2022 you issued a prevention of future deaths notice on the Trust due to concems raised during the inquest which concluded on 4" February 2022 The matters of concern are as follows Irrespective of the reason for a person's mobility reducing, if it does so and this is a known risk factor then notice must be taken of it and appropnate steps taken. Medical staff should follow the Trust's protocols and perform and document a VTE risk assessment when the reduction in mobility is reduced (from their baseline) even if it is not known if! how long the reduction will continue All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts. if a patient is to be reviewed, then a specific plan should be placed on to the care plan so that everyone knows what is needed to be done All staff should be aware of a patient's relevant past medical history. Junior staff should consult more senior staff if they are unsure of the effect that anticoagulation will have on anti-psychotics or other medication and are thus concerned about administering this In responding to these concerns. | would like to take this opportunity to express again the Trust's condolences to her family regarding the death of Sheila Actions taken above the recommendations within the internal review are primarily to address the gaps in junior Doctors understanding and prompts to escalate concerns regarding physical health. To this end the Medical Director for medical trainees will be updating the Trust induction to include physical health Norfolk Headquarters Suffolk Headquarters Hellesdon Hospital, Endeavour House. Drayton High Road, Norwich NR6 5BE 8 Russell Road, ipswich, (P21 2BX emergencies alongside the existing information on psychiatric emergencies. This includes being alert to the potential risk of diagnostic overshadowing. This will be replicated within the local induction and the junior Doctor handbook. This refresh includes the importance of VTE assessment and prompt action in respect of administering prophylaxis, as well as clear guidance on when to escalate concerns based on clinical findings. The Medical Director for junior Doctors will also be liaison with our acute hospital colleagues to reinstate the joint workshops held prior to the pandemic which shared learning and skills and promoted positive networking Handover between junior Doctors and other medical staff will be underpinned by the Situation Background Assessment Recommendation (SBAR) framework. This will ensure that patient history, emerging concerns and necessary action including escalation where necessary are known, recorded and acted on. Inpatient wards across the organisation utilise and upload the SBAR tool into patient records to assist with ward reviews and handovers. The SBAR document is built upon at each handover, therefore building up a comprehensive history of the patient. All agency and bank staff will be offered the "3 Ps" training which covers “Prevent, Promote, Protect” - observations and assessment, health promotion and screening. This will be available to ail staff from support worker to ward manager level, the format is a set of e-learning modules accompanied by a workbook. The physical health team are rolling out “bite size” training across the trust including focus on VTE and thrombolisation, this training will be face to face. We have set up a working group to work with our flexible working colleagues to support an education ‘passport’ for health workers which will include; acute and chronic conditions, NEWS2 (deteriorating patient), managing Insulin and use of protective personal equipment (infection control measures) amongst other subjects. The Chief Medical Director will be speaking to regional colleagues about the challenges for a mental health hospital to manage serious physical health conditions. This is with a view to improving understanding of relevant expertise and core business leading to improvements in communication and collaborative working | hope that these actions go some way to assure you how seriously the Trust has taken the findings of this tragic incident, and our commitment to improve physical health care and outcomes for our patients. Yours sincerely Nortotk Headquarters Suffolk Headquarters Hellesdon Hospital Endeavour House. Drayton High Road, Norwich NRG 5BE 8 Russell Road, Ipswich, IP21 2BX
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