Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0121, written 25 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 | 25 Apr 2022 |
|---|---|
| Reference | 2022-0121 |
| Deceased | Kathryn Millard |
| Coroner | Ian Brownhill |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Medway NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Mid Kent and Medway Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD Telephone: New and Current Cases: 03000 410502 General Enquiries: 03000 410503 Email: KentandMedwayCoroners@kent.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. T h e C h i e f E x e c u t i v e o f t h e M e d w a y N H S F o u n d a t i o n T r u s t 1 CORONER I am Ian Brownhill, assistant coroner, for the coroner area of Mid Kent and Medway 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 Kathryn Lynda Millard died on 13 May 2021 at the Medway Maritime Hospital. An investigation into her death was commenced. The investigation concluded at the end of the inquest on 28 March 2022. The jury found that the medical cause of death was: 1a Pulmonary Embolism 1b Deep Venous Thrombosis 1c II Fractured Spine, Diabetes Mellitus The jury’s conclusion was that Ms Millard’s death was an accident. They gave a short narrative conclusion in addition, which read: She died from a complication of necessary medical treatment. 4 CIRCUMSTANCES OF THE DEATH On the 10th May 2021 Kathryn Millard fell backwards down a flight of stairs at a property where she was working. She was admitted to Medway Maritime Hospital with a fractured spine. At Medway Maritime Hospital, she was immobilised upon admission and a decision was made that she should be prescribed stockings to avoid deep vein thrombosis and dalteparin as prophylaxis. The stockings were not applied. In respect of dalteparin, this was decision was initially withdrawn due to an identified risk of bleeding and the prospect of surgery. When it was determined that there was to be no surgery, the treating consultant indicated that dalteparin should be commenced. That decision was not recorded in Mrs Millard’s medical notes. The dalteparin was not given. On 12 May 2021, Mrs Millard began to have green vomit. The nursing staff were concerned and asked for her to be reviewed by a doctor. An unidentified individual came to the ward and saw Mrs Millard. That individual did not record their interaction in Mrs Millard’s notes nor did they speak with the nursing staff. On the morning of 13 May 2021, Mrs Millard had a cardiac arrest. Despite efforts by staff, she could not be resuscitated. 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. – (1) The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented. It is concerning that this treatment plan was not recorded properly in the deceased’s notes. (2) The medical records indicated that at least one doctor had indicated that Mrs Millard should have anti-embolic stockings applied. However, the nursing staff gave evidence that they were not aware of this. (3) The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs Millard’s medical records. It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing staff. 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 21 June 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 The family of Kathryn Millard The other interested persons within the inquest The legal representatives of the above. In addition, I have sent this to: The Care Quality Commission 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. 9 Signature: Ian Brownhill Assistant Coroner Mid Kent and Medway 25 April 2022
2 responses 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.
Action Plan (KM) PFD REG 28 - 07.06.22 Service Trust wide Action Description What will be the final outcome? (include required KPIs or evidence of delivery) Executive Lead Care Group Action/ Work stream Lead Key milestones to be achieved Start date Due date Revised due date Completion date RAG Assurance Mechanisms Comment/narrative Risk Register number (if applicable) Surgical Services NO Share the outcome of the SI investigation report at M & M meetings. The aim is to raise clinician awareness around such incidents. Divisional Medical Director Orthopaedics The Prevention of Future death was received by the Trust in April. The outcome of the inquest and content of the PFD will be shared with the Surgical team, Care Group Meeting and Divisional Governance Board. Aug-21 N/A Jul-22 Complete - approved Minutes from relevant meetings that information has been shared to be submitted to the governance team. The PFD and action plan will also be discussed at the Divisional Governance Board for learning. N/A Surgical Services NO Change the 'Ward based structure to team based. This will allow hierarchical tree with responsibility on specific individuals attending. Changing the set up of the clinical team on the ward will allow the hierarchical tree with responsibility on certain individuals attending (either that person or their buddy) rather than the ghosting that happens with ward based cover. Divisional Medical Director Orthopaedics Completed Aug-21 N/A Nov-22 Complete - approved This is now embedded in practice. Ward-based structure has now been transitioned to team based structure. N/A Surgical Services NO Ensuring good record keeping. All Consultant ward rounds to be dictated and affixed into notes by respective secretary Consultant. Any advised given by the surgical doctors on Ward rounds must be documented and communicated to Nurses. Divisional Medical Director Orthopaedics Service Manager None Aug-21 N/A Jan-22 Surgical Services NO Audit of Consultant ward rounds and post take to be undertaken. Surgical Services NO Nursing training towards routine TED application for all inpatients and its application should be the norm, unless contra-indicated eg DVT. This is to review the completeness and thoroughness and effectiveness of documentation. Outcome is that there is continuity in patient care and high quality patient care is maintained. Divisional Medical Director Orthopaedics Service Manager Raised awareness and knowledge. Nursing should be aware of when patients require TED stocking and should liaise with clinicians if not prescribed. This should improve patient care and lead to better outcome for the patient. Director of Nursing Orthopaedics Head of Nursing & Matron None Aug-21 N/A Jan-22 Complete - approved An audit of documentation on EPR took place in January 2022. An action plan is being complied to address the issue identified and EPR documentation will be re-audited in the next two months (End of August). Complete - approved An audit of documentation on EPR took place in January 2022. An action plan is being complied to address the issue identified and EPR documentation will be re-audited in the next two months. Completed Aug-21 Aug-21 N/A Aug-21 Complete - approved Compliance with expected practice will be monitored during ‘Ward Rounds’ and ‘Drug Rounds’ and lessons learned will be shared at ward meetings. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed. N/A N/A N/A Surgical Services NO Audit of Nursing notes on completeness and handover - gaps noted on communication to medics / escalation/ failure to document the correct weight of the patient etc. This will ensure that all actions from the clinicians have been completed or escalated where needed. Outcome is that there is continuity in patient care and high quality patient care is maintained. Director of Nursing Orthopaedics Ward Manager & Matron The questions on the documentation audit Jun-22 Monthly N/A On track Compliance with expected practice and lessons learned will be shared at ward meetings, Care Group Meeting and Divisional Governance Board. Matron's documentation audit utilising 'Gather' is to commence from June. N/A Page 1 of 1
07 June 2022
Mid Kent and Medway Coroners
Cantium House
2nd Floor
Maidstone
Kent
ME14 1XD
Medway Maritime Hospital
Windmill Road
Gillingham
Kent
ME7 5NY
Dear Mr Brownhill
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Re: Mrs Kathryn Millard
I am writing in response to your report dated 26 April 2022, concerning the care provided
to Mrs Millard whilst at Medway NHS Foundation Trust. Your report highlighted three
matters of concerns which are listed below. For clarity I will respond to each of your
concerns in the order they are raised;
1. The direction of the most senior clinician, the orthopaedic surgeon, was not
documented in the medical records and was not implemented. It is concerning that
this treatment plan was not recorded properly in the deceased’s notes.
In relation to the concern of poor record keeping by the medical doctor, the Orthopaedic
team have discussed the outcome of the Serious Incident Investigation report at the
junior doctor’s grand round.
Medical doctors have been reminded of the importance and principles of effective
healthcare record keeping, which is a minimum standard. The quality of records should
meet the Generic Record Keeping Standard, General Medical Record keeping
Standards (Royal Academy of Physicians) and Standards for the structure and content
of patient records (Academy of Medical Royal Colleges).
The adherence to national and Trust standards will be audited on a monthly basis and
the results of the audit will be shared at local and divisional governance board meetings
to ensure compliance and improvement in practice.
2. The medical records indicated that at least one doctor had indicated that Mrs
Millard should have anti-embolic stockings applied. However, the nursing staff
gave evidence that they were not aware of this.
The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are
prescribed and applied when indicated by the medical team. Safety messages and local
teaching have occurred to ensure that nurses escalate incidents where an appliance
has been indicated, but not prescribed.
Since the recipient of this letter, the team has again sent out safety message to all
nursing staff as a reminder of the expected standard. Compliance with expected practice
will be audited monthly, and monitored during ‘Ward Rounds’ and ‘Drug Rounds’ and
lessons identified will be shared at ward meetings.
3. The nursing staff were concerned on the 12 May 2021 as to the presentation and
prognosis of the deceased. Whomever attended (if anybody did in fact attend), did
not make any entry into Mrs Millard’s medical records. It is concerning that the
Trust were not able to identify this individual and that they did not discuss the
patient’s presentation and prognosis with the nursing staff.
As you highlighted, the Trust was unable to ascertain if Mrs Millard was indeed
assessed by a clinician on 12 May 2021 when her condition deteriorated as there is no
record of this care taken place. This does not meet the standards we would expect
and all staff have been reminded that all patient contacts are to be recorded in the
patient medical record in line with national and Trust guidelines.
An audit of healthcare record keeping (including compliance with relevant Trust policy)
will take place on an annual basis Trust wide. In addition, compliance with the
expected documentation standards are included in the Ward to Board Assurance and
Accreditation Process, which will be rolling out from 27 June 2022.
The results of such audits will be reported via the Trust’s Governance structures for
Quality, including outcomes and exceptions. In addition, ongoing regular audits will be
undertaken using the Trust ‘Gather’ reporting system by Care Groups to ensure that
ongoing record keeping is of the required quality. This will help to inform local audit
programmes and to measure the impact of actions taken, supporting improvement
activity.
The Trust is committed to learning and improving the standards and quality of our
services and care to ensure the best possible experience and outcomes for our
patients, their families and carers. I hope that my response, in addition to the included
action plan provides assurance that we have taken your concerns seriously and
responded to them to ensure we implement lessons identified.
Yours sincerely
Interim Chief Executive Officer
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