Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0318, written 14 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2022 |
|---|---|
| Reference | 2022-0318 |
| Deceased | Kenneth Goodwin |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Executive, Stockport NHS Foundation Trust
1
CORONER
I am Lauren Costello, Assistant Coroner, for the Coroner Area of 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 14th June 2022 I commenced an investigation into the death of Kenneth
Goodwin then aged 86 years. The investigation concluded at the end of the
inquest on 9th October 2022. At the end of the Inquest, I recorded a narrative
conclusion that Mr Goodwin died as a result of an acute subdural haematoma
following a fall.
The medical cause of death being
1a Traumatic Subdural Haematoma
II Cholecystitis
1
4
CIRCUMSTANCES OF THE DEATH
Kenneth Goodwin was admitted to hospital on 1st June 2022 with severe abdominal pain
and was treated for sepsis from gall stones and cholecystitis. The infection for which he
was admitted was gradually improving during his admission following conservative
treatment.
Mr Goodwin’s family confirmed to the hospital that he was a falls risk.
On 3rd June 2022 he had a fall in hospital and banged his head, likely on his hospital bed.
The fall occurred after being transferred from one ward to another during the night. He was
transferred at 21:09 and the fall occurred at 01:40 before a falls risk assessment had been
completed on the new ward. After transfer he displayed signs of confusion and wished to
get out of bed to use the bathroom despite being catheterized. The Inquest heard that it
was unclear if the bed rails were used.
As a result of the fall, he developed an acute subdural haematoma. This was treated
conservatively but despite treatment he deteriorated and died on 9th June 2022 whilst still
at Stepping Hill Hospital.
Stepping Hill Hospital have taken steps to reduce nighttime transfers for patients
experiencing confusion or who are at risk of falls.
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 could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTER OF CONCERN is as follows. –
(1) The Inquest heard that the transfer process between wards for patients at risk of
falls does not require a specific written confirmation that a handover in relation to
that risk has taken place.
(2) The falls risk assessment on the new ward was not completed for just over 4.5
hours. The Inquest heard that the target time for this assessment is within 6
hours, a length of time which is of concern for patients transferred at night,
displaying signs of confusion, and already identified as a fall risk.
(3) The Inquest heard that the use of signs on beds to visually identify falls risk to the
staff is not consistently used.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
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 6th December 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 Interested
Persons:
of Hempsons, solicitors to the Trust
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
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.
9
DATE
SIGNED BY CORONER
14th October 2022
3
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.
Stockport NHS Foundation Trust Oak House Stepping Hill Hospit91 Poplar Grove Stockport SK2 7JE Private and confidential By email. Ms Lauren Costello Assistant Coroner Coroner's Court Mount Tabor Mottram Street Stockport SK13PA 5 December 2022 Dear Ms Costello Re: Kenneth GOODWIN (Deceased) I am writing to you further to the inquest of the late Kenneth Goodwin, which concluded on 9 October 2022 and the concerns you have raised relating to the care provided to Mr Goodwin by this Trustin June 2022. I am grateful to you for highlighting these concerns and for providing me with an opportunity to respond. I Matron for Surgery, asked , , Matron for Patient Experience and Quality Improvement and Governance and Quality Manager for the Division of Surgery to investigate on my behalf. They have reviewed the matters of concern which arose during the inquest and these are: , Deputy Director of Quality Governance, The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place. · · We can confirm that the Trust does have i.n place a formal hand over document that, amongst other important information, highlights whether or not a patient is at risk of falls. This information is completed and handed over for all patients who are transferred from one area to another. In Mr Goodwin's case, it has come to light that staff on ward D6 used a hand over document that was not formally authorised for use and this did not contain the patients falls risk status. This therefore meant that although standard process would ensure that the handover of risk of falls would be communicated upon patient transfer, that this did not happen in th.e case of Mr Goodwin, and for that we apologise. Action - The Trust's formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust's 'Risky Business' weekly bulletin and also via targeted e-mails from the · divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the h.andover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliat>ly utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance .of communication upon· transfer of all appropriate risks. · The falls risk assessment on the new ward was not completed for just over 4.5 hours. The Inquest · heard that the target time for this assessment is within 6 hours, a length of time which is of concern for patients transferred at night, displaying signs of confusion, and already identified as a fall risk. The Trust can confirm that there is a six hour standard for risk assessments to be completed following transfer of a patient to a ward. This window allows the receiving team to admit the patient into their care, undertake all appropriate care for the patient, and document any necessary risk assessments. This timeframe is in line with other NHS acute providers and recognises the time required to complete accurate medical documentation whilst caring, for the patient. _We do however recognise that alongside this process that there must be a reliable process to identify risks to patients on handover, such as the risk of falls. Alongside the admission process documents referenced above, the transfer process includes transfer of the patient's medical records and formal patient handover document to provide the receiving ward with all necessary details relating to patient risk factors. The formal handover document is imperative for patients regardless of time of transfer and where the patient is transferred to within hospital to ensure that there is a standardised and reliable method of immediate communication regarding key patient information. We again apologise that in the case of Mr Goodwin that the correct formal handover document was not used. The Inquest heard that the use of signs on beds to visually identify falls risk to the staff is not consistently used. The Trust uses a maple leaf sign to identify patients at risk of falls. In the case of Mr Goodwin we have identified that an agency nurse was not aware of the need for the use of the maple leaf sign. The Trust recognises that all temporary staff must be made familiar with Trust policy and practice for each area in which they work. Action - The requirement for the use of the maple leaf sign, identifying patients at risk of falls, was re launched across the Trust on 15 November 2022, via the Trust's 'Risky Business' weekly bulletin and also via targeted e-mails from the divisions governance teams. The requirement for the use of the maple leaf sign will also be added on all agency staff induction check lists to ensure that their use is explained to staff who are new to the organisation. Completion of the checklists is already induded within the audit pmgramme. Once again I would like to thank you for giving me the opportunity to respond to your concerns and trust that my response has been helpful to you. If there are -any areas where I could provide further clarification, please do not hesitate to get in touch. Yours sincerely, Chief Executive 2
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