Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0239, written 4 Aug 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 Aug 2022 |
|---|---|
| Reference | 2022-0239 |
| Deceased | James Curry |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Tameside and Glossop Integrated Care NHS Foundation Trust and the Greater Manchester Health and Social Care Partnership 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 25th November 2021 I commenced an investigation into the death of James Robert Curry. The investigation concluded on the 30th June 2022 and the conclusion was one of Narrative: Died from the recognised complications of a fractured neck of femur following a fall when the necessary operation took place outside the recommended timescale and followed a lengthy wait in the emergency department. The medical cause of death was 1a) Bronchopneumonia 1b) Fracture Neck of Left Femur 4 CIRCUMSTANCES OF THE DEATH James Robert Curry was active and lived independently. Around lunchtime on 13th November 2021, he had an accidental fall. He was taken to Tameside General Hospital. He was found to have a fractured neck of femur. He waited approximately 12 hours on a trolley in a draughty corridor before he was admitted to AMU. Planned surgery on 14th November did not take place due to lack of capacity in theatre and a shortage of orthopaedic beds. On 15th November, it was decided he required on echocardiogram, the reasons were unclear. That took place on 16th November. The operation did not proceed on that day due to the lack of theatre capacity. On 17th November 2021 he was operated on. He was in a weakened condition due to repeated NBM and not being able to mobilise. On 18th November he began to deteriorate rapidly and died at Tameside General Hospital on 18th November 2021 from bronchopneumonia. 1 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. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. 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 29th September 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 namely on behalf of the Family, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 Alison Mutch HM Senior Coroner 04.08.2022 3
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.
Date: 28 September 2022 Ms A Mutch HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms. Mutch Re: Regulation 28 Report to Prevent Future Deaths – James Robert Curry Thank you for your Regulation 28 Report dated 04/08/22 concerning the sad death of James Robert Curry on 18/11/21. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Mr. Curry’s family for their loss. Thank you for highlighting your concerns during Mr. Curry’s Inquest which concluded on 30 June 2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services. The inquest concluded that James’ death was a result of 1a) Bronchopneumonia 1b) Fracture Neck of Left Femur. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken. I hope the response below demonstrates to you and Mr Curry’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case. Concern 1:- 1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go t o AMU. As a consequence, on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance. The Trust recognise that hip fractures are very common, especially in older people where the impact of a fracture can have a significant impact upon their lives. At Tameside and Glossop Integrated Care NHS Foundation Trust (ICFT), it is recognised that there have been significant challenges throughout the hip fracture pathway. The Trust’s response to the Covid pandemic and prolonged increased activity impacted on the service’s ability to treat and manage patients within the appropriate processes and timeframes. At the time of Mr Curry’s admission to Tameside Hospital the Trust, like other areas of the country, was 4th Floor, Piccadilly Place, Manchester M1 3BN A3 experiencing sustained and significant operational pressures within the Emergency Department (ED) and wider hospital and were responding to continuous Covid challenges and pressures. The Trust had separate areas for Covid positive and non Covid patients as set out in NHS England national planning guidance which contributed to delays in Mr Curry being triaged and subsequently transferred to an appropriate bed. The Trust has now been able to reinstate previous care pathways due to a decline in the national incidence of Covid positive cases. This means that the bed base of trauma and orthopaedics has been increased to near pre-pandemic levels. The Surgical and Medical Division have worked closely together to design and implement an enhanced bed allocation process. The process supports those patients with a fracture d neck of femur from the moment that the patient has their fracture confirmed in the ED thro ugh to admission to a trauma and orthopaedics bed. The pathway redesign has included both in- and out of hours actions to take by the clinical teams, with support from the Trust’s patient flow team. Each Trust bed meeting, which occurs five times per day, highlights any patient within the ED who will require a Trauma and Orthopaedic beds due to a fractured neck of femur. 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. The Trust recognise that best practice and NICE guidance states that patients that have sustained a hip fracture should have timely surgery to repair the injury within 36 hours of admission, wh ere the patient is clinically stable to undergo surgery. To manage these patients within the appropriate timeframe alongside competing priorities within the trauma and elective services, the Division of Surgery, Women’s and Children’s services (SWC) have reviewed and strengthened their processes. The trauma and orthopaedic department run a daily trauma meeting, where all patients with a fractured neck of femur and who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of all patients with a fractured neck of femur and who are awaiting surgery is also provided to the surgical bed meeting each morning, including status of patient and current wait time for surgery. For those patients who can proceed to surgery, this will be scheduled to take place within the 36 hours timeframe to support compliance with NICE guidance. If this is not possible due to a theatre not being available, an urgent review of the entire trauma and elective lists that day will be undertaken. A clinical and operational discussion determines how the patient can be accommodated and a plan devised. The detailed plan is then enacted with the approval of the Divisional Management Team (DMT) and patient scheduled into theatre. For those patients who are deemed not fit for surgery, the trauma coordination team supports the orthopaedic and anaesthetic clinicians to determine the clinical plan. This plan is discussed at the daily trauma planning meeting. For patients who may require diagnostic tests as part of their pre-operative optimisations, daily tracking of these is also included within the daily planning meeting. 4th Floor, Piccadilly Place, Manchester M1 3BN A4 Where the Trust is not able to meet the 36-hour timeframe for surgery for a patient with a fractured neck of femur, a clinical incident report is submitted. Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the “NOF Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manager. Compliance is monitored through regular internal returns. The Trust submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma co-ordinators daily. The Trust have implemented a Divisional fractured neck of femur improvement programme which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance. Actions taken or being taken to share learning across Greater Manchester. 1. Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE. 2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums. In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester. I hope this response demonstrates to you and Mr. Curry’s family that NHS GM has taken the concerns you have raised seriously and is committed to work together as a system including our service users, carers and families to improve the care provided. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Gill Gibson Deputy Chief Nurse NHS GM Integrated Care 4th Floor, Piccadilly Place, Manchester M1 3BN A5
Tameside and Glossop Integrated Care NHS Foundation Trust Integrated Governance Unit Tameside and Glossop Integrated Care NHSFT Silver Springs Fountain Street Tameside and Glossop imeeeren Care NHSFT Ashton Under Lyne Ashton Under Lyne Tameside OL6 9RW OL6 SRW PC ae 15" September 2022 Private and confidential To be opened by the addressee only HM Coroner, Miss Mutch Via Email Dear Miss Mutch ! am writing further to the inquest touching upon the death of Mr James Robert Curry (who died on 13!" November 2021) which concluded on 30" June 2022 and the subsequent Regulation 28 Notice issued to the Trust. | hope to be able to build upon the issued raises within your report, and set out below my response in terms of what we already are doing and wie we plan to do. | have outlined these in order of the concerns raised. Concern 1:- 1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the tess heard that the prolonged wait was due to a shortage of beds within the Trust. 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance. The Trust recognise that hip fractures are very common, especially in older people where the impact of a fracture can have a significant impact upon their lives. At Tameside and Glossop Integrated Care NHS Foundation Trust (ICFT), | acknowledge that there have been significant challenges throughout the hip fracture pathway. The Trust’s response to the Covid pandemic and increased sustained activity have impacted on the service's ability to treat or manage patients within the appropriate processes and timeframes. At the time of Mr Curry’s admission to Tameside Hospital.the Trust were experiencing sustained and significant operational pressures within the Emergency Department and wider hospital and were responding to continuous Covid challenges and pressures. The need for the Trust to have segregated areas for Covid positive and non Covid positive patients also contributed to Mr Curry’s additional! waiting time in the Emergency Department and ultimate transfer to the most appropriate bed. jax] ve} disability Everyone GIG confident hief Executive _ Matters Beeson Hy mh © L— Page 1 Page Tameside and Glossop Integrated Care NHS Foundation Trust For those patients are not deemed fit for surgery, the trauma coordination team supports the orthopaedic and anaesthetic clinicians to determine the clinical plan. This plan is discussed at the daily trauma planning meeting. For patients who may require diagnostic tests as part of their pre operative optimisations then daily tracking of these is also included within the daily planning meeting. Where the Trust are not able to meet the 36 hour timeframe for surgery for patient with a fracture neck of femur a clinical incident report is submitted. Following the incident a root cause analysis is completed by the Trauma Coordinators to identify reasons for the delay and opportunities for learning. The root cause analysis investigations are then reviewed weekly in the “NOF Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manger. For assurance of performance with the National Institute for Health and Care Excellence (NICE) Clinical guidance the Surgery, Women’s and Children’s Division are monitoring compliance on an ongoing basis. The Trust submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma co-ordinators daily. The Trust have implemented a Divisional fractured neck of femur improvement programme which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance. | hope that this response has provided assurance that the Trust has taken your comments and concerns seriously and taken action to minimise the risk of such event occurring again. Should you require any further information, please do not hesitate to contact me through the Legal Services Team on 0161 922 5020. Yours sincerely, Executive Director of Nursing and Integrated Governance For and on behalf of Karen James OBE, Chief Executive Officer f jat |v] disability Everyone IES confident Chief Executive - Ei a ‘in| (9) : Matters ff EMPLOYER Chair - A2
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