Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0246, written 6 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 | 6 Aug 2022 |
|---|---|
| Reference | 2022-0246 |
| Deceased | Ernest Bacon |
| 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: Secretary of State for Health and Social Care, Tameside and Glossop Integrated Care NHS Foundation Trust 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 20th January 2022 I commenced an investigation into the death of Ernest Bacon. The investigation concluded on the 26th July 2022 and the conclusion was one of Narrative: Died from sepsis contributed to by the complications of an accidental fall. The medical cause of death was 1a) Sepsis; 1b) Bronchopneumonia; II) Fractured Neck of Femur, Chronic Obstructive Pulmonary Disease, Ischaemic Stroke 4 CIRCUMSTANCES OF THE DEATH Ernest Thomas Bacon had an accidental fall at his home address. He was admitted to Tameside General Hospital where it was identified he had a fracture to the neck of femur. He was operated on. He had an ischaemic stroke whilst an inpatient. On 16th January 2022 at 19:50, his NEWS score was recorded as 7. He was prescribed fluids but not intravenous antibiotics. The Trust Policy was not followed in relation to intravenous antibiotics being given within 1 hour. He was not given intravenous antibiotics until about 22:38. The decision not to follow the Trust Sepsis Policy was not recognised and not escalated. He continued to deteriorate. On 17th January 2022 he died from Sepsis at Tameside General Hospital. 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 when Mr Bacon became unwell on 16th January the Trust was staffed at weekend/OOH doctor numbers. This meant that there were a very limited number of doctors available within the hospital when the ward staffed asked for a clinical review when Mr Bacon triggered for sepsis on the NEWS2 system. The Inquest heard that the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model; 2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover; 3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis; 4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy. The reason for non-escalation was unclear. 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 1st October 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following on behalf of the Family, who may Interested Persons namely find it useful or of interest. 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 Alison Mutch HM Senior Coroner 06.08.22 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.
• Department of Health & Social Care Alison Mutch HM Senior Coroner Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK13AG Dear Ms Mutch, 20/12/2022 Thank you for your letter of 6 August 2022 about the death of Ernest Thomas Bacon. I am replying as Minister with responsibility for Mental Health and Women's Health Strategy, including patient safety, at the Department of Health and Social Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Booth's death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). I understand that several actions have been taken by Tameside and Glossop Integrated Care NHS Foundation Trust following Mr Bacon's death. A retrospective Root Cause Analysis was conducted into the clinical care of Mr Bacon and in particular the response to his raised National Early Warning Score and recognition of sepsis. A number of learning points were identified as a result of the investigation and the findings have been used to inform the Trust's sepsis improvement plan. In addition, since July 2022, the Trust has increased the medical rota to include a further junior doctor to provide additional support and in recognition of the acuity and activity of the out of hours medical provision. The CQC also continues to engage with the Trust and has received assurance regarding a review of the sepsis pathway and the associated retraining for all staff. Sepsis can be a devastating condition and patients rightly expect the NHS to be able to recognise and diagnose it early and provide the highest quality treatment and care. Over recent years, the NHS has become much better at spotting and treating sepsis quickly. This means that more people are being identified as at risk of sepsis and mortality rates are falling. However, we know that some patients who deteriorate with sepsis are still not being diagnosed quickly enough. In April 2018, a National Early Warning Score patient safety alert was issued to support providers to adopt the revised National Early Warning Score (NEWS2) to detect deterioration in adult patients, including those with suspected sepsis. However, it is recognised that sepsis guidance could be improved to ensure appropriate room for diagnostics and clinical judgement. In response to growing evidence of the need to update sepsis guidance, the Academy of Royal Medical Colleges (AoMRC), in partnership with the Faculty for Intensive Care Medicine,
'1'7:kj Tameside and Glossop Integrated Care NHS Foundation Trust · Tameside and Glossop Integrated Care NHSFT Fountain Street Ashton Under Lyne Tameside OL69RW Integrated Governance Unit Silver Springs Tameside and Glossop Integrated Care NHSFT Ashton Under Lyne OL6 9RW 27th September 2022 Private and confidential To be opened by the addressee only HM Coroner, Miss A Mutch Via Email Dear Miss Mutch I am writing further to the inquest touching upon the death of Earnest Bacon (who died on 17th January 2022) which concluded on 25th July 2022 and the subsequent Regulation 28 Notice issued to the Trust. I hope to be able to build upon the issued raises within your report, and set out below my respon'se. I have outlined these in order of the concerns raised. In response to the concerns raised, the Trust instigated an immediate strategy meeting with all the Divisional Directors -to collaborate, assess and understand the actions requireq to address the issues raised. · Concern 1:- The inquest heard evidence that there staffing numbers of doctors and a reliam;e on junior doctors to cover wards at the weekend was part of the national staffing model. / 17th On Sunday night 15th January 2022, the night when Mr. Bacon's condition sadly deteriorated, the level of junior doctor cover for the medical wards overnight exceeded that set out in national guidance by the Royal College of Physicians (2018). The actual number of doctors on call at that time were three Tier 1 doctors and one Tier 2 doctor covering non-covid medical beds. _At the time that Mr: Bacon died the Trust were experiencing a significant increase in clinical activity as they were responding to the Omicron Covid wave. Medical staffing is continuously monitored and is reported to the Trust wide bed meeting, which occurs 5 times per day, this includes weekends. Any known shortfalls in the rota are known, and proactive action is taken on these to provide cover. Whilst the Trust d.oes acknowledge that the junior doctor rota meets national_ guidance it does need to be strengthened furtherto support increased activity and acuity in the ward areas. The Trust is currently progressing a business case to increase the level of junior doctor provision which alsb aims to reduce reliance on locum and agency doctors. M Cl) ll0 ro a.. ElH'a disability B t:. confident EMPLOYER fi'7:kj Tameside and Glossop Integrated Care NHS Foundation Trust Concern 2: - As a result of the availability of the doctors Mr Bacon was not reviewed face to face but via a telephone call. His notes were not viewed and the seriousness of his condition was not recognised. Please may I refer this point to the narrative which we have provided for concern 3, where I have described the improvement work and on-going actions to support the recognition of sepsis across the Trust. Concern 3:- The Trust policy required that Mr Bacon be treated for Sepsis, but he was not placed on the Sepsis pathway and a further reviewed did not take place until another doctor was - asked to review him, despite his NEWS score continuing to trigger for sepsis. Immediately following the inquest touching the death of Mr. Bacon the Trust completed a retrospective root cause analysis investigation into the. clinical care of Mr Bacon, and in particular the response to his raised National Early Warning Score (NEWS) and recognition of sepsis. This was also retrospectively reported on the Trust's incident reporting electronic system. A number of learning points were identified as a result of the investigation and the findings have been used to support a Trust wide sepsis improvement plan. The sepsis improvement project is being led by the Head of Nursing for Professional Standards and Assurance and the Trust Medical Lead for Patient Safety. The improvement plan builds on previous actions taken by the Trust to support the early detection and application of the Sepsis 6 care bundl~. The comprehensive plan include~ a number of workstreams which will support improvement on: ' • Recognition of sepsis • Application of the Sepsis Care Bundle • Prescribing of antibiotics - • Blood Cultures • Medical assessment of deteriorating' patients. The Trust has had a Trust wide a focus on· World Sepsis Day which was held on the 13th September 2022. The Trust's Safer Care team have held a focus on sepsis week which took place over the week of 12th -18th September 2022. The'objective of the week was to raise the profile of sepsis throughout the organisation and to reiterate recognition and management of suspected sepsis. During the week results of the sepsis audit and a detailed action plan on the sepsis improvement work was shared at the Trust's Grand Round and the Managing Deteriorating Patient Group. In addition to this, ?-minute briefings on recent sepsis incidents have been developed and are being shared across the Trust. The Safer Care team have also created sepsis related scenarios to engage teams in identifying red flags for sepsis and encourage adherence to the use of sepsis care bundles. N fili Throughout September the Safer Care team has been visiting the wards a11d community bases to carry out interactive tool box talks. Information regarding the use of the sepsis care bundles and the use of the sepsis trolley (for inpatient clinical areas) has also been shared with clinical teams. Clinical teams have been participating in sepsis scenario sessions, which supports the identification of red flags for sepsis. mm disability B!i confident EMPLOYER r.!7:kj Tameside and Glossop Integrated Care NHS Foundation Trust The key messages for the Trust wide project are: 'Think could this be sepsis' Identification of sepsis Implementation of sepsis .care bundle • • • • The seJ?sis six To provide internal assurance spot check audits have been implemented to specifically look at compliance with the sepsis pathway. The audits have commenced and include a review of 1 0 patients each month. Where compliance with the pathway has not been present, an incident form will be completed contemporaneously. The sepsis improvement work has also been report~d to the Trust's Quality and Governance · Committee, which is chaired by a Non-Executive Director. A's a direct action following this meeting additional nursing posts were agreed which will specifically support clinical teams in sepsis identification, training and compliance across the organisation. Concern 4:- The nursing team recognised that Mr Bacon was triggering for sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy. The reason for non-escalation was unclear. . As explained in the narrative answering point 3, a retrospective investigation was completed following Mr. Bacon's inquest. The investigation report identified that whilst the nurse who conducted the set of clinical observations at 19:50 hours on 16th January 2022 recognised and acted upon his raised early warning score (which was scoring 7), by inserting a cannula and performed blood tests, they did not recognise that Mr. Bacon was displaying two red flags for sepsis. As the nurse had not recognised the fact that Mr. Bacon had sepsis, then the sepsis care bundle was not initiated. Had the red flags been recognised, the sepsis care bundle could have been implemented at an earlier point, it is also likely that this information would also had been relayed to the on call. doctor, which may have led to a timeiier response. It is hoped that the Trust wide improvement plan and actions that the Trust have taken so far would reduce the risk of this occurring again. Along with the sepsis ·improvement project, the Trust has also been reviewing the NEWS scoring system and how this is recorded. The NEWS score is a well established physiological scoring tool which was introduced at the Trust many years ago. The NEWS tool has an established training package in place for clinical staff and compliance with the tool is part of the regular Trust audit program. Compliance with the tool •is monitored via the Deteriorating Patient group which reports directly into the Executive Lead Service Quality Assurance Group . . . m When clinical observations are performed as part of NEWS the staff in the Trust are required to manually calculate and record the score. The Trust acknowledge that manual ·calculation and recording can be open to human error, therefore significant work has been undertaken to improve this and I can confirm that the Trust is currently at the Pre-Market Stage of procuring a new Electronic Patient Record (EPR) to replace Dedalus Lorenzo in March 2025. OHi disability B !i confident . EMPLOYER " r.!7:bj Tameside and Glossop Integrated Care NHS Foundation Trust Whilst the new EPR may provide a long term electronic NEWS solution in 2025, in the interim the plan is to deliver an inhouse electronic solution. The Trust has an embedded electronic NEWS application currently in use across our Emergency Department (eNEWS). The agreed proposal is a_ pilot of the eNEWS application across our surgical wards with a viewto improving the accuracy and speed of data recording, and to eliminate errors in early score warning calculation. We are aiming to commence the pilot prior to December 2022. At the time of Mr' Bacon's death, the delay in recognising and treating his sepsis was not reported on the Trust's electronic reporting system. As a result of your concerns outlined--above in relation to incidents, the Trust's incident trigger lists have been circulated widely throughout the organisation with a reiteration of the importance of incident reporting. In addition to this, there has been a Trust wide focus on incid,ent reporting throughout the month of September 2022. This work has been underway across the organisation and is being led by the Assistant Director of lr"ltegrated Governance throughout, culminating in the Trust's Patient Safety Conference on October 6th 2022. This programme of events and, activities s~eks to engage staff at all levels and focusses on identification of incidents or near misses, incident reporting, acting on ahd learning from incidents. I hope you will feel that the Trust has taken appropriate action as a result of your findings, however sh_ould you wish to discuss any aspect of this or seek further assurance please do not hesitate to contact me through the Legal Services Team · Executive Director of Nursing and Integrated Governance - Acting on and behalf of , Chief Executive Officer QJ b.O ro a.. mra msability EJC'. confid~nt EMPLOYER S':11 ' .a-- .fflll . . - , UJJ (®)
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