Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0060, written 22 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 | 22 Feb 2022 |
|---|---|
| Reference | 2022-0060 |
| Deceased | Christopher Osland |
| Coroner | Kate Thomas |
| Coroner area | North East Kent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Product related deaths |
| Organisation named | East Kent Hospitals University 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of the East Kent Hospitals University NHS Trust 1 CORONER I am Kate Thomas Assistant Coroner, for the Coroner’s Area of North East Kent 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 the 19th May 2021 the Senior Coroner commenced an investigation into the death of Christopher George Osland. The investigation concluded at the end of the inquest bef ore a Jury on the 22md February 2022. The conclusion was narrative verdict. 4 CIRCUMSTANCES OF THE DEATH On the 30th March 2021, Mr Osland was admitted in to Kent and Cant erbury Hospit al f ollowing an Ischaemic Stroke. He suffered a further Cardiac Arrest on the 1st April 2021 and was transferred to ITU were he made neurological improvement. He still req uired ventilator support but was subject to weaning programme whereby he breathed wit hout assistance for period of 3 hours at a time. On the 26th April 2021, during hand over and within a time f rame of no more t han 10 minutes, Mr Osland became increasingly hypoxic, the exact cause of which could not be ascertained, but which lead to Cardiorespiratory Arrest and catastrophic Ischaemic Brain injury. Although he benef itted f rom a f ixed monitoring system within his room (hereinaf ter ref erred to as the ‘room monitor’), the alarm volume had b een d ecreased t o a p oint where the nurses sat outside his room were not alerted to events. Furthermore, the fixed monitor in Mr Osland’s room had become ‘OFF COMS on t he 19th April 2021 f rom the Central Monitor at the Nurses station, (hereinafter referred to as the ‘central monitor’), and theref ore no alert was sounded and nurses stood at that station similarly were unaware on Mr Osland’s distress. The evidence at the inquest was that not all nurses knew that the sound level of alarms on room monitors could be reduced and so did not check alarm volume when coming on shif t. It was also determined that whilst the central monitor would sound an alert when a room monitor went ‘OFF COMS, once this alarm was silenced, it was no t t he c ase t hat t he room monitor would in itself reconnect to the central monitor, although the screen on the central monitor would continue to display that there was no connection. There was no evidence at Inquest that once the ‘OFF COMS’ alarm had been silenced, presumably on the 19th April 2021, any steps had been taken to ensure the room monitor and central monitor were reconnected. The evidence at the Inquest was the subject to the room monitor being disconnected t o the central monitor, both units were working correctly. Mr Osland did not regain consciousness and died on the 12th May 2021 af ter the withdrawal of clinical support. The medical cause of death was 1a) Hypoxic Ischaemic Encepalopathy 1b) Prolonged Hypoxia leading to Cardiorespiratory arrest 1c) Extensive lef t Cerebellar Inf act involving lef t Hemi Medulla secondary to lef t Vertebral Artery dissesecton II Hypertension, Hypercholesterolemia 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) Nursing staff are unaware that the room monitor volume could be reduced to the point where it was not audible outside the room – as a result, the volume of the room alarm was not part of hand over equipment checks. 2) The circumstances in which the room monitor alerts were reduced were not documented, and accordingly subsequent staff would not be aware that they had been so reduced 3) Af ter silencing the ‘OFF COMS’ alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor. 4) No steps had been taken to respond to the ‘OFF COMS’ notification on the central monitor screen which had persisted for the 5 days prior to the 26th April 2021 5) Specifically in respect of points 3 & 4, it is unclear as to when the ‘OFF COMS’ disconnection between the room and central monitor would have been rectified had it not come to light after Mr Osland’s arrest. It was unclear what steps nurses were supposed to take when confronted with an ‘OFF COMS’ alert or screen notification. 6) 6 ACTION SHOULD BE TAKEN 1. 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 6th April 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 ( Son ) • • • Quality Care Commission • NHS England and Improvement ( Wellington House 133- 135 Waterloo Road, ( Wife ) London SE1 8UG) 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 f orm. 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 KATE THOMAS, Assistant North East Kent. 22nd February 2022
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.
S Trust Offices Kent & Canterbury Hospital Ethelbert Road Canterbury, Kent CT1 3NG Kate Thomas HM Assistant Coroner Coroner’s Area of North East Kent Cantium House 2nd Floor Maidstone, Kent ME14 1XD 30 March 2022 Dear Madam , Chief Executive Mr Christopher George Osland – PFD Response Thank you for your Prevention of Future Death Report dated 22nd February 2022 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Mr Christopher George Osland on 12th May 2021. I understand that during the course of the inquest you heard evidence that revealed matters giving rise to various concerns that need to be addressed to prevent a future death. I will address your concerns in chronological order: 1. Nursing staff are unaware that the room monitor volume could be reduced to the point where it was not audible outside the room, as a result, the volume of the room alarm was not part of handover equipment check and 2. The circumstances in which the room monitor alerts were reduced were not documented, and accordingly subsequent staff would not be aware that they had been so reduced. The volumes on the monitors have now been defaulted to 8-10 (which is the highest volume on the machine) and cannot be reduced by the ICU (Intensive Care Unit) staff. ICU staff are now not able to reduce and set the alarms on these machines themselves and this can only be carried out by the Trust’s Electrical and Mechanical Engineering Department (EME) on request. As a result of this change, volumes of the alarms will not routinely be required to be discussed at handover. However, if EME have been requested to change the volumes, this will be documented along with an individualised risk assessment in the patient record. In future, a review of alarm levels will take place as part of our configuration of current ICU monitors but I can assure you that volumes will be set at a level which will be agreed by the configuration working group which comprises of critical care, medical devices, EME and GE Healthcare (manufacturer of the monitors). 3. After silencing the ‘OFF COMS’ alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor and 4. No steps had been taken to respond to the ‘OFF COMS’ notification on the central monitor screen which had persisted for the 5 days prior to the 26th April 2021. Since this incident, EME have carried out an inspection of the ICU Department’s electrical supply system. As a result, they identified faults with the cabling which could have affected the connection of monitors to the central monitor. The entirety of the cabling in ICU at Kent & Canterbury Hospital has been replaced to improve connectivity and since this has been carried out there have been no issues with connectivity. If the ‘OFF COMS’ alert appears, the process is to inform the Nurse in Charge and report this to EME as soon as the staff are made aware of the issue. The process of reporting issues to EME is now more robust with logging and receipt of calls and the Trust now uses a dedicated IT system (EQUIP) which allows for a review of any issues that are outstanding or recurring themes that need to be acted upon. Additionally, we have implemented twice daily audit checks on the central monitoring system to ensure that it is connected with every monitor in ICU - these checks are recorded in the unit diary. 5. Specifically, in respect of point 3 & 4, it is unclear as to when the ‘OFF COMS’ disconnection between the room and central monitor would have been rectified had it not come to light after Mr Osland’s cardiac arrest. As outlined in the GE Healthcare log report which was adduced in evidence at the inquest, the central monitoring system disconnected from the monitor in Mr Osland’s room on 19th April 2021 and re-connected itself on 26th April 2021, around 20 minutes after his cardiac arrest. It is accepted that had Mr Osland not suffered a cardiac arrest we would have been unable to tell you with any confidence when the fault would have come to light. This has now been rectified and I refer you to our responses above. 6. It was unclear what steps nurses were supposed to take when confronted with an ‘OFF COMS’ alert or screen notification. Before Mr Osland’s death the process for ICU staff confronted with an ‘OFF COMS’ alert or screen notification was to report the matter to EME. However, it is accepted that this was not widely known by nursing staff and I refer to the above response in paragraph 4 which details how the Trust has improved the reporting process. I can confirm that as a result of this incident, the inquest and your PFD Report the Critical Care Steering Group considered all matters associated with Mr Osland’s care and will ensure all recommendations are addressed and continue to be monitored. Lastly, I hope I have provided you with the relevant assurance that the Trust has taken the incident and your concerns seriously and we will continue to strive to offer high standards of clinical care to our patients in the ICU setting. Yours sincerely Chief Executive
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