Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0248, written 8 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 | 8 Aug 2022 |
|---|---|
| Reference | 2022-0248 |
| Deceased | Gerwyn Rees |
| Coroner | Robert Sowersby |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Bristol and Weston NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 8 August 2022 REF: 21890 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, University Hospitals Bristol and Weston NHS Foundation Trust (‘UHBW’) 2. Head of Clinical Governance, UHBW CORONER 1 I am Robert Sowersby, Assistant Coroner for the Area of Avon 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 20 January 2021 an investigation commenced into the death of Mr Gerwyn John REES, aged 77. The investigation concluded at the end of the inquest on 3 August 2022. The medical cause of death was: 1a) Frailty and hip fracture 2) Delirium The narrative conclusion of the inquest was as follows: Mr Gerwyn Rees was elderly and frail, and at a high risk of sustaining serious injury from falling, when he was admitted to the Bristol Royal Infirmary on 28 November 2020. The staff looking after him in hospital did not take adequate steps to prevent him from falling, and he fell over on 29 November 2020, sustaining a fractured hip. He underwent surgery, but his condition continued to deteriorate over time, and in January 2021 he was discharged to Westin Care Home in Whitchurch for palliative care: he sadly died there on 17 January 2021, as a result of both general frailty and the hip injury sustained in hospital. The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 4 CIRCUMSTANCES OF THE DEATH Giving a litte more detail, the circumstances of the death were that: • Mr REES was 77 years old and was in poor general health • He had a pre-existing brain injury, frontal lobe damage, a history of alcohol misuse and a significant psychiatric history • He experienced episodes of confusion and had memory problems • He mobilised at home with a stick or with a frame, or with assistance • Before the admission during which he broke his hip, Mr REES had a recent previous admission (from October to 25 November 2020), during which he had been investigated for gallbladder problems – an admission that he had not been expected to survive I note from the RCA report that Mr REES had experienced an inpatient fall (at Callington Road Hospital) immediately prior to that admission, and further inpatient falls (at the BRI) during it • • Mr REES had been discharged home from that earlier admission on 25 November 2020 • While he was at home he appears to have had a number of falls over the ensuing days, and on 28 November 2020 (just three days after his discharge) he and his partner called 999 • When the ambulance attended, the paramedics determined that Mr REES had postural hypotension (which meant he was often dizzy or lightheaded when he stood up); they were also concerned that he may have a heart condition, and were worried that he appeared not to be looking after himself • The paramedics took Mr REES to the BRI, where he was admitted the same day • The following day (29 November 2020) Mr REES had his falls risk assessed on Ward A413 • That assessment was carried out by a Nursing Assistant, and then signed off by a Registered Nurse • • At that time falls risk assessments were performed in line with the BRI’s then- current Enhanced Care Observation and Meaningful Observation Policy (‘the ECO Policy’) In my judgment, when his falls risk was assessed on 29 November 2020 Mr REES clearly and unarguably represented a high falls risk – there was a significant risk that he would fall, and a very significant risk that if he did fall, then he might sustain serious injury • To reiterate, at the time of that assessment Mr REES was: o 77 years old o Frail and appeared not to be looking after himself o Mobilised with a stick or a frame, or with help, when he was at home o Had fallen at least once, and possibly more than once, in the last 3-4 days o Had fallen more than once during his last (recent) inpatient stay at the BRI o Had a known brain injury (which both made him particularly vulnerable if he did fall, and also contributed to episodes of confusion and memory loss) o Had been admitted with identified postural hypotension, which created an obvious falls risk. • Notwithstanding those obvious (and significant) risk indicators, Mr REES was assessed as requiring Level 2 Enhanced Care Observations: I note from looking at the relevant table in Appendix A of the then-in-force ECO Policy that this equates to a “low risk” • According to the text accompanying “ECO level 2”, that level of observations is to be used when: The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL “The patient displays occasional unsafe behaviour (which is not expected to result in serious harm) or is at avoidable risk of mild levels of harm.” (Emphasis in bold added.) • • The wording in this part of the table contains two distinct elements: the first relates to the likelihood of a fall taking place, the second relates to the likely seriousness of the outcome if a fall does happen It appears self-evident to me that a frail 77-year old with a pre-existing brain injury is at risk of really serious harm if s/he falls over in hospital, and therefore that ECO level two could not in any way be an appropriate categorisation for someone in Mr REES’s position, irrespective of whether he could properly be said to exhibit only occasional unsafe behaviour • Mr REES had his first inpatient fall later that same day – at around 12.30pm – although he did not sustain any serious injury at that time • He was then transferred to ward A515 • I was told in live evidence that Mr REES’s falls risk had been reassessed after his first inpatient fall, and that he was moved to A515 as an “ECO level 3” patient, although that evidence was not supported by the contemporaneous medical records, or indeed by much of the written evidence that was submitted to me in the course of my investigation • Shortly after moving to Ward A515 Mr REES was left unattended by the Nursing Assistant who was supposed to be keeping an eye on him (she had gone to tell the Nurse in Charge that she thought he needed to be observed more closely); Mr REES tried to stand up to follow her out of the room, suffered his second inpatient fall of the day, and fractured his hip (an injury which later made a significant contribution to his death) • Although Mr REES underwent successful surgery, he never recovered fully from this injury, and he later died as a result of both his frailty and the fracture. 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 and in the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – • I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020 • However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death • The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2 • Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment she initially • When I then questioned (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL • “clinical judgment” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time) I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse can have suggested to me that ECO 2 was ever appropriate for Mr REES • The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse and Matron (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy • Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question • For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe. 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 Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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 26 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 – the family of the deceased. I have also sent it to the Care Quality Commission who may 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 08/08/2022 Signature Robert Sowersby Assistant Coroner Area of Avon The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
Trust Headquarters
Marlborough Street
Bristol BS1 3NU
Email:
website: www.uhbw.nhs.uk
26 September 2022
Letter sent by e-mail t
Mr Robert Sowersby
HM Assistant Coroner
Coroner’s Court
Old Weston Road
Flax Bourton
Bristol
BS48 1UL
Your ref: 21890
Dear Mr Sowersby,
RE: Regulation 28 report to prevent future deaths relating to the inquest of Mr Gerwyn
John Rees
Thank you for your report relating to the inquest of Mr Rees raising your concern that there
remains a risk that future deaths will occur unless action is taken. We value insights from
outside of the Trust to enable further improvements to be made to the quality and safety of
our services.
Following the receipt of your Regulation 28 report, we have reflected on our Root Cause
Analysis report relating to Mr Rees and we have reviewed our Enhanced Care Observation
and Meaningful Activities Policy. We have summarised the work we are already doing to
improve our patient safety incident investigations.
The Trust takes patient falls very seriously and is committed to reducing the number by
mitigating the risks of falling as much as possible. Where falls do occur, we are committed
to learning from these events to identify any areas for improvement in our patient care. The
dementia, delirium and falls team has clinicians from nursing and allied health professionals
background who provide support, specialist assessments and advice to ward based teams
across the Trust. The ward based teams also identify and have falls champions within each
team to facilitate and cascade evidence based practice in falls prevention and care. The
Team also has updated the falls prevention information leaflet as well as providing
simulation based bespoke training to ward teams in the management of falls.
We have reflected on the Root Cause Analysis carried out in this case with particular regard
to the concerns you have raised. When assessing the falls risk for new patients admitted to
hospital, we consider many aspects including their past medical history, reason for
admission, and the presentation of the patient at that time. In Mr Rees’ case he was
assessed on admission and assigned ECO level 2. At the time of presentation Mr Rees
was found to be alert, orientated, not agitated, and calm. Mr Rees was able to hold a
coherent conversation and was able to understand instructions to sit and wait for help to
assist him to mobilise. Mr Rees was not putting himself at risk e.g., he was not attempting
to mobilise on his own. We recognised that Mr Rees was an elderly gentleman with a
history of previous falls and underlying mental health and medical health issues. Whilst
this history helps to inform a risk assessment, it is used in conjunction with a patient’s
presentation at the time. Mr Rees was not confused or agitated in his presentation to
trigger a higher level of observation under the Enhanced Care Observation Policy at that
time. As Mr Rees was able to engage in a conversation and understand instructions, his
behaviour was considered to be predictable as he was able to follow instructions to wait for
assistance. When Mr Rees sadly suffered a fall on A413, this should have prompted a re-
assessment and assignment to ECO level 3. We accept that the communication around
the ECO level 3 when Mr Rees was transferred to ward A515 was suboptimal and this has
been considered in the Root Cause Analysis.
As a direct result of this case, we have reconsidered our Enhanced Care Observation
(ECO) and Meaningful Activities Policy and are in the process of implementing a revised
policy to take on board our learning from this case. It is expected that this updated policy
will be in place by November 2022. The updated policy removes the levels of 1, 2, 3, and 4
for ECO, which sometimes causes confusion amongst practitioners and replaces the levels
for all inpatients requiring observations with:
Intermittent supportive observation,
• General observation,
•
• Continuous supportive observation – within eyesight and
• Close supportive observation – within arm’s length.
The ECO guidance now provides a holistic view of patients, instead of a risk assessment
based on falls or confusion alone, i.e. accounting for any behavioural changes, confusion,
previous/current history of falls, requiring supervision or assistance for transfers and
mobility, lack of insight etc. There is additional guidance on appropriate care and referral
for persons with learning disabilities, dementia/delirium, alcohol or drug withdrawal and
patients with acute mental illness in an acute care setting. The updated policy also
provides guidance on using the multi-disciplinary team’s expertise and input, for e.g.,
occupational therapists for advice on meaningful activities for patients with ECO and
referrals to appropriate specialist care teams (liaison psychiatry, dementia, delirium and
falls team). In addition, to provide equitable and consistent care for all our patients, we will
look at strengthening the ECO policy along with our partners in North Bristol NHS Trust.
It is expected that reducing the reliance on a ‘numbered’ level of care for ECO and
reinforcing the actual level of care a patient requires, staff would provide adequate and
appropriate enhanced care observation for patients who require it. In addition, considering
the holistic needs of a patient would allow staff to provide the most appropriate level of care
for a patient rather than a reliance on risk assessments for falls or confusion alone.
Once the updated policy has been approved, key staff groups affected by the ECO policy
will be provided support, education, and training in applying the policy in practice. This will
include display signs in ward areas, a meaningful activities list and task kits, and additional
training to the ECO team from the dementia, delirium and falls team.
In relation to the Trust’s investigatory processes, it may be helpful to explain that since
2020 University Hospitals Bristol and Weston NHS Foundation Trust has been learning
about and preparing for the transfer to the new national Patient Safety Incident Response
Framework. The Patient Safety Incident Response Framework supports the development
and maintenance of an effective patient safety incident response system that integrates four
key aims:
1. Compassionate engagement and involvement of those affected by patient safety
incidents
2. Application of a range of system-based approaches to learning from patient safety
incidents
3. Considered and proportionate responses to patient safety incidents
4. Supportive oversight focused on strengthening response system functioning and
improvement.
Unfortunately, pace was impeded by the Covid-19 pandemic and the need to prioritise
clinical service provision however in the past 12 months practical preparations have taken
off to enable transfer to the new framework by June 2023. A number of changes have
already been made which are relevant to this response with more currently underway and
planned which are summarised below.
• A new model for patient safety investigation has been agreed and funded. This will
provide for a small central team of expert investigators, including a human factors
specialist, who will carry out the majority of patient safety incident investigations
which meet the criteria for a full patient safety incident investigation. It is anticipated
these roles will be in place by the end of 2022/23.
• The criteria for a full investigation will include those events for which a full
investigation is nationally mandated and events related to key patient safety risks
identified as priorities for learning and improvement within UHBW’s Patient Safety
Incident Response Plan. This plan will be published on our website by the end of
2022/23.
• The expert investigators will be required to have completed the relevant specialist
investigation training and to meet the standards and competencies which have now
been set nationally.
• Seven members of staff working in patient safety roles in UHBW have undertaken
the new level 3 investigation training made available by the Healthcare Safety
Investigation Branch (HSIB) in early 2022 (or possess a recognised Masters level
• equivalent). Further level 2 patient safety training modules have
been made available by the HSIB in the past couple of weeks and UHBW staff in
relevant roles are accessing these over the next few months.
• There will be alternative methods for reviewing and learning from patient safety
events that do not meet the criteria for a full patient safety incident investigation.
• Governance arrangements for learning and improvement from patient safety
incidents will continue and be enhanced.
We trust that our response provides you with the assurance you require with regards to
consistent rigour of patient safety incident investigations and supports our staff to better
identify the level of observation appropriate to patient needs.
Kind regards,
Chief Executive
Head of Quality and Patient Safety
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