Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0289, written 19 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 | 19 Apr 2022 |
|---|---|
| Reference | 2022-0289 |
| Deceased | Sebastian Nottage |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Railway related deaths |
| Organisation named | Surrey and Sussex Healthcare NHS 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Sebastian NOTTAGE A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Chief Executive Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH 2 CORONER Miss Anna Crawford, HM Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST The inquest into the death of Sebastian Nottage was opened on 14 July 2020. The inquest was resumed on 11 March 2022 and the conclusion was handed down on 18 March 2022. The medical cause of his Nottage’s death was: 1a. Multiple injuries and electrocution The inquest concluded with the following narrative conclusion: On 30 June 2020 Sebastian Nottage died on the railway line between Salfords Station and Earlswood Station, having sustained fatal injuries as 1 a result of being hit by a London bound train. Prior to his death, he tripped and fell into the side of the train, resulting in his death. . 5 CIRCUMSTANCES OF THE DEATH Sebastian Nottage was 26 years old and had Asperger’s Syndrome and Attention Deficit Disorder. He also had a history of Anxiety, Insomnia, and Opioid Dependence. On 29 June 2020 he was admitted to East Surrey Hospital where he was treated for acute pancreatitis. He was seen initially in the Emergency Department and then in the afternoon he was transferred to Tandridge Ward, which is the Surgical Assessment Unit. Shortly before 8am on the morning of 30 June 2020 he left Tandridge Ward without telling any members of staff that he was doing so. Thereafter he made his way to the railway line between Salfords Station and Earlswood Station where he sustained fatal injuries as a result of being hit by a London bound train. The court heard that a ‘Seven-day short stay booklet for admission/discharge’ is completed when a patient is admitted to Tandridge Ward and that the booklet seeks and records information in relation to a variety of topics which are pertinent to a patient’s care. The court found that there was an omission to complete fully the booklet at the time of Sebastian’s admission to the Surgical Assessment Unit and thereafter. The court also found that the admitting nurse relied on information recorded in the Emergency Department notes (some aspects of which were incomplete) to complete some parts of the booklet and did not check the information with Sebastian or his mother who was accompanying him. The court accepted the opinion of the Court’s expert 2 nursing witness, that these matters fell below expected standards of nursing care, albeit they did not cause or contribute to Sebastian’s death. The Court heard evidence from Nursing. She gave evidence, amongst other things, that: the Trust’s Head of (i) (ii) (iii) She could not assist with whether there are any formal policies presently in place in relation to the timeframe in which the booklet ought to be completed, but said that in her professional opinion it ought to be completed in full within 24 hours of admission to the unit. She did not consider that the booklet should be handed over to night staff to complete, if it was not fully completed on the day of admission. This differed to the view of the Court’s expert nursing witness. She considered that it was appropriate for the booklet to be based in part on information which had previously been recorded in the Emergency Department notes without checking it directly with the patient. Again, this differed to the view of the Court’s expert nursing witness. 3 6 CORONER’S CONCERNS The Coroner’s concerns are set out below. The MATTER OF CONCERN is: - There is no clear guidance in place in relation to the timeframe for the full completion of the ‘Seven-day short stay booklet for admission/discharge’ and the steps to take if the booklet has not been fully completed on the day of admission to the unit. The Coroner considers that further guidance and/or training on this matter may be required. - There is no clear guidance in place in relation to the manner in which the ‘Seven-day short stay booklet for admission/discharge’ ought to be completed, and particularly whether it is permissible to rely on information recorded in the Emergency Department without checking it directly with the patient. The Coroner considers that further guidance and/or training on this matter may be required. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 4 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Sebastian Nottage’s family 3. Network Rail 10 Signed: Anna Crawford H.M. Assistant Coroner for Surrey Dated this 19th day of April 2022 5
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.
Chief Executive Surrey and Sussex Healthcare NHS Trust Ms Anna Crawford H M Assistant Coroner for Surrey HM Coroner’s Court Station Approach Woking Surrey GU22 7AP By recorded delivery post Dear Ms Crawford Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH 29 June 2022 Regulation 28 Report — response by Surrey & Sussex Healthcare NHS Trust Inquest touching upon the death of Seb Nottage This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to section 7(2) to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 18 May 2022, made subsequent to the inquest into the death of Mr Noffage which was concluded on 18 March 2022. The Trust was given until 12 July 2022 to respond to the coroner, pursuant to Regulation 29(5) Coroners (Investigations) Regulations 2013. Background: Mr Nottage attended the Emergency Department at East Surrey Hospital on 29 June 2020 and was assessed by a junior doctor at around 11 .OOam. He reported a ten day history of epigastric abdominal pain, fever, headache, vomiting, diarrhoea and a cough. He was referred to the surgical team and admitted to the Surgical Assessment Unit (SAU) with suspected pancreatitis. He had a past medical history of osteoporosis, osteomalacia and hiatus hernia. He also had a diagnosis of Asperger’s syndrome, anxiety and attention deficit hyperactivity disorder (ADHD). On admission he was deemed to have capacity and he was noted by staff to be able to communicate his needs and appropriately request pain relief. He stayed overnight on SAU. At around 715am on 30 June 2020 he left the ward having earlier told staff that he wanted to go for a walk. Just after 9.OOam the police telephoned SAU and informed staff that Mr Nottage had been hit by a train and had died. HM Coroner Regulation 28 Report: The concerns raised by HMC are in relation to this completion of the Trust’s “7 day Short Stay Booklet” and specifically: Putting people first Delivering excellent, accessible healthcare An Associated University Hospital of Brighton and Sussex Medical School There is no clear guidance in place in relation to the timeframe for the full 1 completion of the ‘Seven-day short stay booklet for admission/discharge’ and the steps to take if the booklet has not been fully completed on the day of admission to the unit. The Coroner considers that further guidance and/or training on this matter may be required. There is no clear guidance in place in relation to the manner in which the 2. ‘Seven-day short stay booklet for admission/discharge’ ought to be completed, and particularly whether it is permissible to rely on information recorded in the Emergency Department without checking it directly with the patient. The Coroner considers that further guidance and/or training on this matter may be required. Trust response: The current 7- day Short Stay Booklet Admission/ Discharge and Daily Evaluation outlines the expectation that the nursing staff will complete the information within the booklet during the early stages of the patient’s admission. It is not possible to provide a definitive time frame within which this is completed, as this will be dependent upon the patient’s admission pathway (whether they are emergency or elective) the time of day they are admitted and their capacity and presentation at the time. The booklet is being reviewed and will be reprinted to incorporate enhanced instructions regarding completion of the booklet. Specifically, the wording at the top of each page will be: “Page 1-14 complete within 24 hours and check daily to ensure completion.” In addition, at page 15 onwards it will state: “Please check pages 1-14 have been completed or ensure explanation for any gaps is written on continuation sheet.” The Trust has revised the teaching session for “Ward documentation” which is part of the Ward Ready Course. I attach a copy of the revised lesson plan detailing the content provided to all new nursing staff. This training is delivered via the Trust’s Practice Development Team to all new members of the nursing workforce during their induction programme. The current nursing workforce will be reminded of the expectations and importance of completing documentation via the daily Ward Handovers, daily Safety Huddles, and monthly Ward Manager and Matron Meetings. In addition, the Matron’s Monthly Documentation Audit will continue to address compliance with completion of documentation, and any training requirements for wards and individuals. In respect of the manner in which the booklet ought to be completed, page 8 currently outlines the expectation that the nursing staff should not solely rely on information that is already with the patient’s medical records. Specifically, it states: ‘Take the patient history, do not rely on information from the medical notes.” A patient’s medical records “travel with” the patient during their admission and they are reviewed by the nursing staff at the time of their admission to wards. However, where a patient has capacity andl or family and / or carers are present.the nursing . staff will be reminded to engage with the patient and / or family and / or caters during the admission process so that there is a further opportunity to obtain information. Page 2 of 3 Nursing staff will be reminded not to reply solely on the medical records during the above teaching sessions. These reminders will be via the daily Ward Handovers, daily Safety Huddles, and monthly Ward Manager and Matron Meetings. As part of the Trust’s teaching programme for all nursing staff, it is planned (completion in August) that there will be a simulation video to demonstrate the “Perfect Admission” which will incorporate engagement with patients, how to extract information to ensure there is completion of documentation and will include the 7- day Short Stay Booklet Admission! Discharge and Daily Evaluation. In September 2022, the Trust will roll out Digital Documentation (an electronic patient record system). The information from the 7-day booklet will be “built in” to the digital programme, and there will be one record in which all information is accessible to all clinicians. The digital documentation will largely replicate the content of the current paper booklet to ensure that the same information is captured, and it has been reviewed as part of the digital programme to ensure it reflects current best practice. It is envisaged that the electronic patient record will enable all the clinicians to access the patient’s entire record; and it will help clinicians to ensure there is a safer, leaner and “real time” documentation of the care they provide to patients. Nurses when accessing the electronic system will have a ‘landing page’ for their allocated ward where all automated patient tasks are viewed and are allocated a time frame for completion. From “Care Compass”, nurses are able to access the clinical documentation on safety assessments and medications due to be given. An important feature in “Care Compass” is the ability to set tasks in accordance with the relevant NICE standards or local standards. These tasks ace colour coded indicating the status that the Nurse in Charge will be able to view and manage in their teams. The updated paper booklet will be retained for use as a downtime resource in the event of any temporary outage of the electronic system, once it is live. Yours sincerely Chief Executive Officer Surrey & Sussex Healthcare NHS Trust Page 3 of 3 Ward documentation - Lesson plan for ward ready Venue I hour Nightingale/Seacole Session duration Lesson date various Tutor The Practice Development Team (various) Aims of session: To provide staff with an understanding of how to complete ward documentation correctly, this to include the f-day short stay bedside safety booklet risk assessments and care plans and 7- day short stay booklet. Learning outcomes: By the end of the session delegates will be able to: . Understand how to complete workbooks for patient documentation Understand the importance of timely completion of both work books . . Understand the need to check all documentation on each shift and handover to next shift any missing assessments . Understand the importance of involving patients, relatives and carers in completing assessment paperwork. Handouts Copies of both ward documentation booklets for their referral. Link to veoo The eect assessment Time 5 mins - Content Introduction - housekeeping, phones off Session rules agreement — confidentiality respect, listening and sharing Overview of documentation — Introduction to both . mins workbooks and what they are used for. frainer Activity Resources Set out expectations presentation . Samples of reflective cycles I F 15 mins . nns 15 mins . Workbook short stay assessment booklet - assessment pages 1-14 To be completed within 24 hours with patient and their relatives not using medical notes. For daily care plan to be documented daily and pages 1-14 checked for completion daily Outstanding assessments handed over to next shift. Watch video for how to complete a patient assessment. . Presentation! video . . In pairs complete assessment on one another Group work 7-day short stay bedside safety booklet risk assessments and care plans — Go through each assessment tool and how to use. presentation . Documentation booklets Presentation slide deck of each i page of documentation Video Blank documentation forms Pens Presentation slide deck of each page of documentation Printed scenarios to give to each group Group scenarios nns Group work Pens Blank 7-day short stay bedside safety booklet risk assessments and care plans flme Tutor ActivitylContent Student Activity Resources 5 mins Fluid balance monitoring demonstration Presentahon Slide deck of fluid monitoring Fluid balance practice individual practice in groups Supervised individual Bnk fluid monitorin S 5mins Wrap up and close Discussion
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