Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0114, written 19 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Apr 2022 |
|---|---|
| Reference | 2022-0114 |
| Deceased | Richard Scott-Powell |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Richard Scott-Powell A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Dr Chief Executive Holy Cross Hospital Haslemere Surrey GU27 1NQ 2 CORONER Miss Anna Crawford, HM Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST An inquest into the death of Richard Scott-Powell was opened on 4 March 2021. The inquest was resumed on 6 April 2022 and concluded on 7 April 2022. The medical cause of Mr Scott-Powell’s death was: 1a. Covid 19 Pneumonia 2. Spinal Cord Injury due to a fall on 19 March 2020, Previous Stroke The inquest concluded with a narrative conclusion as set out below. 1 5 CIRCUMSTANCES OF THE DEATH The inquest concluded with a narrative conclusion as follows: Mr Scott-Powell was 61 years old and had a past medical history which included a previous stroke. On 19 March 2020 he suffered a fall at his home address. It has not been possible to establish how the fall occurred. As a result of the fall Mr Scott-Powell sustained a spinal cord injury, as a result of which he was tetraplegic. He was treated initially at East Surrey Hospital where he underwent a tracheostomy and was cared for on a ventilator in the Intensive Care Unit. On 18 July 2020 he was transferred to the Lane Fox Unit in London where his tracheostomy was converted to a mini-tracheostomy and he was weaned from the ventilator. On 4 January 2021 Mr Scott-Powell was admitted to the Holy Cross Hospital in Haslemere, Surrey for nursing care and long-term neurorehabilitation. On 6 January 2021, he was noted to have developed a temperature and on 7 January 2021 he had a negative COVID-19 test before testing positive for COVID-19 on 11 January 2021. It has not been possible to establish when or how Mr Scott-Powell contracted COVID-19. Mr Scott-Powell died at the Holy Cross Hospital in Haslemere on 18 January 2021. His death was caused by COVID-19 Pneumonia and contributed to by his pre-existing spinal cord injury and his previous stroke. The spinal cord injury and the stroke contributed to his death by making him more 2 susceptible to developing COVID-19 pneumonia and compromising his ability to recover thereafter. 3 6 CORONER’S CONCERNS The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr , a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. The MATTER OF CONCERN is: 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 4 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr , a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr , GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 5 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Mr Scott-Powell’s family 3. Surrey and Sussex Healthcare NHS Trust 4. South East Coast Ambulance Service 5. Medi4 Ambulance Services 10 Signed: Anna Crawford H.M Assistant Coroner for Surrey Dated this 19th day of April 2022 6
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.
Holy Cross Hospital Haslemere Surrey GU27 1NQ
Telephone:
Fax:
Miss Anna Crawford
HM Assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking, Surrey
GU22 7AP
10th June 2022
Dear Miss Crawford,
The Death of Richard Scott-Powell - A Regulation 28 Report
Further to the email of 19th April 2022, sent on your behalf by
, I have pleasure in providing this response.
We accept your findings that our record keeping and monitoring of Mr Scott-Powell showed variability, with some entries
mentioning that his vital signs were ‘okay’ (but without recording the actual measurement), and with a NEWS2 score that
was not followed by appropriate escalation.
NEWS2: Holy Cross has a high number of patients who have prolonged disorders of consciousness, spinal cord injury and
other conditions where standard NEWS2 scores cannot be applied reliably. Specifically, vital signs for a patient who is NOT
unwell may fall outside of what is considered to be the normal range, resulting in abnormal NEWS2 scores. At least 2/3rd
of patients at Holy Cross fall into this category.
A NEWS2 chart was employed on 13th January 2021, with two measurements recorded at 2.50am and 6.00am. It has not
been possible to ascertain why this monitoring approach was adopted for Mr Scott-Powell, a patient with spinal cord
injury, but a high NEWS2 score should, in any case, have triggered closer investigation.
The NEWS2 chart was set aside after the second set of measurements at 6.00am and was not used again.
Training (clinical decision making / patients at risk) - As part of a wider range of learning and development courses, training
is provided to the ward team to facilitate clinical decision-making and escalation as follows: Clinical Decision Making
(Registered Nurses), Identifying Patients at Risk (Health Care Assistants), NEWS2 (Registered Nurses and HCAs) and Sepsis
(Registered Nurses and HCAs). The first two courses are in-house, with NEWS2 and Sepsis being online courses (containing
standard methodologies/protocols). We are in the process of repeating training in these areas for all relevant staff.
The Congregation of the Daughters of the Cross of Liege. Registered Charity 1068661. A company limited by guarantee and registered in England.
Registered Company Number 3492921. Registered Office Address: 29 Tite Street, Chelsea, London, SW3 4JX.
In light of the above, we
have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and
escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into
account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by
our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery),
ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its
implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.
We are also implementing an Electronic Patient Record System in the second half of 2022/23. This will provide better
standardisation over paper records, and will require measured values to be entered (rather than a narrative ‘okay’).
Finally, at the time of Mr Scott Powell’s diagnosis of Covid-19 (13th January 2021), the ward was beginning to manage a
growing number of positive cases among patients, while at the same time experiencing staff reductions due to self-
isolation and Covid infection. It was a time with multiple emergent challenges, and was unprecedented.
We strive for continual improvement and believe that the actions proposed will improve our response should a similar
situation arise.
With kind regards,
Chief Executive
The Congregation of the Daughters of the Cross of Liege. Registered Charity 1068661. A company limited by guarantee and registered
in England. Registered Company Number 3492921. Registered Office Address: 29 Tite Street, Chelsea, London, SW3 4JX.
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