Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0206, written 4 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jul 2022 |
|---|---|
| Reference | 2022-0206 |
| Deceased | Ann Pickering |
| Coroner | David Urpeth |
| Coroner area | South Yorkshire (Western) |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Barnsley District General Hospital, Gawber Road, Barnsley, S75 2EP 2. Kendray Hospital, Kendray Hospital Lodge, Doncaster Road, Barnsley, S70 3RD 1 CORONER I am David Urpeth, Senior Coroner, for the Coroner Area of South Yorkshire West 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 13.7.21, an investigation into the death of Ann Pickering was commenced. The investigation concluded at the end of the inquest on 24.6.22. The conclusion of the inquest was a narrative conclusion, copy attached. 4 CIRCUMSTANCES OF THE DEATH Mrs Pickering began complaining of throat swelling and a sense of choking. Various tests found no issues with her throat or swallowing function. She refused to eat and drink sufficient and was diagnosed with severe anxiety and an eating disorder. She was admitted to Kendray hospital and placed under a s2 MHA order. Following a decline in her physical health she was transferred to Barnsley Hospital where she remained until her death on 1.7.21. The evidence was that there was a delay in recognising the need for an NG tube and actually inserting one. The evidence was that the delay did not cause her death. 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. – During the inquest, evidence showed:- 1. 2. 3. 4. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer Despite recognising an NG tube was required, one was not inserted until the 30.6.21 There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 29.8.22. 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 to all Interested Persons :- Family Barnsley District General Hospital Kendray Hospital 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 Dated: 4.7.22 SIGNED BY DAVID URPETH, SENIOR CORONER SOUTH YORKSHIRE (WEST) 2
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.
h.'/;;., South West Yorkshire Partnership NHS Found tlon Trust ,..1:J.j Barnsley Hospital NHS Foundation Trust Mr DJ Urpeth HM Senior Coroner The Medico-Legal Centre Watery Street, Sheffield South Yorkshire S3 7ES BY EMAIL AND 1ST CLASS POST 26 August 2022 Dear Mr Urpeth, Regulation 28 Response Ann Pickering We write in response to your correspondence dated 4 July 2022, received on 7 July 2022, enclosing a Regulation 28 Report following the inquest touching the death of Mrs Ann Pickering on 24 June 2022. May we offer the family of Ann Pickering our sincere condolences for their loss. The response to the Regulation 28 Report has been prepared and agreed jointly between Barnsley Hospital NHS Foundation Trust, who manage Barnsley Hospital, (BHNFT) and South West Yorkshire Partnership NHS Foundation Trust who manage Kendray Hospital (SWYPFT). The term "service user and patient" are used interchangeably throughout the response. This is to reflect the terminology utilised within each Trust's policies and procedures. In order to respond to your concerns under Section 5 of the Regulation 28 Report we have adopted the same numbering for your ease of reference: 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. Thank you for clarifying that the date referred to above is 17 June 2021. It is recognised by both organisations that the communication between SWYPFT and BHNFT around 17.6.21 was not a standardised consultation and referral process and that improvements are required so that both organisations have clarity on roles and responsibilities. BHNFT and SWYPFT are improving and clarifying the process which includes a protocol that details operational delivery of a safe and effective pathway, which will include: • A clear referral pathway between SWYPFT and BHNFT, including escalation processes where there is a difference of clinical opinion about the need for transfer. • Clarity with regards to advice versus referral and when to access emergency care in a general hospital setting. 1 J;.,• Ii>,.] South West Yorkshire Partnership NHS Found tion Trust r~L:kj Barnsley Hospital NHS Foundation Tru st • Escalation processes that involve both SWYPFT and BHNFT Safeguarding advisors ensuring timely and person-centred decisions are made. An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1 ). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities - for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1 ). 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer. It is recognised by both organisations that improvements are required so that there is clarity on roles and responsibilities around timely decision making and transfer of service user from SWYPFT to BHNFT. We have also addressed this in concern 1 above. The specific detail of these actions is also included in the collaborative action plan (EXHIBIT 1 ). 3. Despite recogmsmg an NG tube was required, one was not inserted until the 30.6.21 In addition to collaborative working between SWYPFT and BHNFT, a review of BHNFT's existing nutrition policy and agreement on meeting a patient's nutritional requirements particularly for detained patients, including where there is a need for restraint will be undertaken jointly. Nutritional support will be provided in a timely manner by staff from the respective Trusts being clear about their roles and responsibilities in their own organisations, and collectively so that delays do not arise. A standard operating procedure to clarify this along with clear timescales will be in place by 30 November 2022 (EXHIBIT 1). 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. In addition to the points above, collaborative working between BHNFT and SWYPFT has taken place to address this point, this includes: (a) Amending the service level agreement between BHNFT and SWYPFT to reflect SWYPFT Section 17 Policy, specifically the section relating to 'service users residing in other hospitals'; (EXHIBITS 1 &2). (b) Amending BHNFT and SWYPFT service level agreement to include section 17 leave arrangements from SWYPFT to BHNFT. (EXHIBIT 2); 2 '•'Li /i-1 South West Yorkshire Partnership ·on Trust NHS Found lh'J;f..j Barnsley Hospital NHS Fou .,dation Tn11st (c) Developing a co-produced protocol that details the operational delivery o f the above, also in (EXHIBIT 1 ). (d) Identification of lead clinical staff, including clear plans for which clinic ian is responsible for each aspect of a patient's management, where they are un der a section and transferred to BHNFT (S17 Leave). Enclosed with the response to the Regulation 28 Report is the jointly agreed a ction plan, timescales and governance arrangements to ensure that Part 5 of your con cerns are fully addressed. (EXHIBIT 1). We hope that this response provides assurance to you and the family of Mrs Pickering , that the concerns identified have been taken seriously and addressed by th e two organisations. Yours sincerely Chief Executive Barnsley Hospital NHS Foundation Trust Chief Executive South West Yorkshire Partnership NHS Foundation Trust Encs: EXHIBITS 1 AND 2 3 t.!1:k1 South West Yorkshire Partnership NHS Foundation Trust r.•1:bj Barnsley Hospital NHS Foundation Trust EXHIBIT 1 Response to Regulation 28 from HM Coroner Mr Urpeth re Ann Pickering - Action Plan Aims/ Targets/ Objectives How this will be achieved What expected outcome will be Ensure there are clear policies and procedures on how patients under a section should be transferred between Kendray Hospital and Barnsley Hospital and what documentation I resource should accompany Amend the service level agreement (SLA) between BHNFT and SWYPFT to reflect SWYPFT Section 17 Policy, specifically the section relating to 'service users residing in other hospitals' Patients will be transferred in a safe and timely manner, supported by the appropriate resource and documentation Amend BHNFT Policy to include section 17 leave arrangements from Kendray to Barnsley Hospital An MDT meeting for all transferred patients will provide timely opportunity to agree the Develop a protocol that details the operational management delivery of the above, plan for the I Who will lead this Deputy Director of Nursing & Quality for BHNFT and Director of Nursing for SWYPFT What evidence will support this Interim guidance SLA for the provision of Mental Health responsibilities for patients detained under the MHA Updated policy Protocol Where this will be reported/ Timescales this will be monitored to - ie Committee/ achieved Group within Interim guidance to SWYPFT and BHNFT staff by 26 August 2022 Existing SLA to be amended by 30 September 2022 Policy amended Mental Health strategy implementation group Safeguarding steering Group Quality & Governance Committee SWYPFT Operational Management Group SWYPFT Executive RAG rating • • EJ South West Yorkshire Partnership NHS Foundation Trust rvl:kj Barnsley Hospital NHS Foundation Trust Management by 30 September Team 2022 Co- produced Protocol to be developed by 30 September • the patient. which will include patient. Staff from the respective Trusts will be clear about their roles and responsibilities • • • • • referral pathway, including escalation where decision to transfer is disputed establishment of MDT meetings within an agreed timeframe to agree management plan Transfer of agreed documentation Transfer of human resource Identification of responsible clinicians t4'i:k, South West Yorkshire Partnership NHS Foundation Trust '4!1:kj Barnsley Hospital NHS Foundation Trust Ensure that NG tubes are inserted in a timely manner Review of existing nutrition policy and agree on insertion requirements particularly for detained patients, including where there is a need for restraint Nutritional support will be provided in a timely manner. Staff from the respective Trusts will be clear about their roles and responsibilities 30 November 2022 SOP in place Matron for Gastroenterology, BHNFT Dr Neela Sundar, Consultant Gastroenterologist for BHNFT Carmain Gibson - Holmes Deputy Director of Nursing for SWYPFT Nutritional steering group & Harm Group • Patient Safety Complete • On track Off track but recoverable • Delayed EXHIBIT 2 SWYPFT patients on section 17 leave Mental Health Act to Barns l ey District General Hospital (BHNFT) Where a service user is required to reside at BHNFT as a condition of his or her to be the Responsible Clinician (RC) granting leave, responsible for the service user's mental health treatment. leave continues Where a service user requires treatment in a general hospital for a ph ys ical disorder and it is expected that the service user will return to SWYPFT follow ing a period of treatment, it is recommended that section 17 leave is used in preference to section 19(1) (formal transfer of power to detain). BHNFT staff are responsible for all aspects of the physical health treatment of the patient. (see below for further information) Under the provisions of section 17 leave, the RC retains overall responsibility for the service user's mental health care and treatment. Staff from SWYPFT are required to remain with the service user whilst on section 17 leave. Where a risk assessment indicates that no escort is required this needs to be agreed with the general hospital and a plan of care including risks and action to be taken should be completed and agreed with the treating clinical teams and the safe guarding lead for BHNFT. SWYPFT will continue to be legally responsible for the service user's mental health care whilst they are on section 17 leave. (the service user will continue to be legally detained to SWYPFT) SUGGESTED ADDITION: Treatment under the Mental Health Act for Mental Disorder. Whilst the patient is in the general hospital treatment for the mental disorder will be under the direction of the RC from SWYPFT. Treatment for the mental disorder will where applicable be authorised under the Mental Health Act. Any treatment which is given for a physical condition will be under the direction of the treating physician's at BHNFT. (use of the Mental Capacity Act will be considered where the patient lacks capacity to consent to the proposed treatment). It is advisable to consult the RC to determine if the service user's mental disorder is impacting on the persons capacity to consent to treatment. The administration of the treatment will be the responsibility of BHNFT staff. An example may be: Service user detained under the Mental Health Act (not holding powers 5(2 ) or 5(4)) Service user with a mental disorder affecting nutrition intake, Advice and discussion with BHNFT physician, recommended treatment by the physician is Naso gastric feeding . The RC will consider if the recommended treatment forms part of the treatment for the mental disorder, if so satisfied they can authorise the Naso Gastric tube feed under the Mental Health Act. (advice can be sought from the Mental Health Act staff in SWYPFT if required) Although the authority to treat may be within the scope of the Mental Health Act, it will be the physician that will decide if it is safe to treat. Determining the service user's capacity to consent to the proposed treatment should be informed by collaborative discussion between the RC and the BHNFT treating physician . The BHNFT physician and team will be responsible for the administration and management of such treatment as clinically indicated by the physician .
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