Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0325, written 18 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 | 18 Oct 2022 |
|---|---|
| Reference | 2022-0325 |
| Deceased | Kenneth Perkins |
| Coroner | Sabyta Kaushal |
| Coroner area | Derby and Derbyshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 University Hospitals Of Derby And Burton 2 Ilkeston Community Hospital 1 CORONER I am Sabyta Kaushal, Assistant Coroner, for the coroner area of Derby & Derbyshire Coroner's 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 14 September 2018 I commenced an investigation into the death of Kenneth PERKINS aged 94. The investigation concluded at the end of the inquest on 28 April 2022. The conclusion of the inquest was that: Kenneth Perkins, date of birth 25th December 1923, of 2 Middlemore Cottages Stanhope Street, Stanton By Dale had a history of recurrent falls. He had a number of co-morbidities - atrial fibrillation, diabetes, trans ischaemic attacks. He attended Royal Derby Hospital on 4th September 2018 following left sided weakness facial droop and confusion. He was agitated , remained confused and lacked capacity. A risk assessment required him to have the assistance of one carer when mobilising; despite this he was wandering in the bed area indepe·ndently without assistance when he fell and hit his head. The subarachnoid bleeding could not be. treated; he was treated palliatively and sadly he died at the Royal Derby Hospital on 11th September 2018. 4 CIRCUMSTANCES OF THE DEATH Mr Perkins was admitted to Ilkeston Community Hospital on 7th June 2018 where full risk assessments were carried out; it was established that he was at high risk of falls. He was transferred to the Royal Derby Hospital on 3rd September 2018. He fell died at the Royal Derby Hospital on 4th September 2018 and died on the 11th September 2018. 5 CORONER'S CONCERNS During the course of the investigation my inquiries 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 MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Mr Perkins was transferred from Ilkeston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls The Royal Derby Hospital did not (but should have) requested a transfer document from Ilkeston. That historv would have Regulation 28 -After Inquest Document Template Updated 30/07/2021 allowed an enhanced level of care and observation to be put in place so as to prevent further falls. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 June 23, 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 exolain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Royal Derby Hospital Ilkeston Community Hospital who may find it useful or of interest. 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. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 18.10.2022 Regulation 28 -After Inquest Document Template Updated 30/07/2021
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.
f411:b1 University Hospitals of Derby and Burton NHS Foundation Trust Royal Derby Hospita l Uttoxeter Road DERBY DE22 3NE Joint Response of University Hospitals of Derby and Burton NHS Foundation Trust and Derbyshire Community Health Services NHS Foundation Trust Date: 26 August 2022 Miss Kaushal HM Assistant Coroner for Derby and South Derbyshire St. Katherine's house St. Mary's Wharf Mansfield road Derby DE1 3TQ Dear Miss Kaushal We are writing in response to your Regulation 28 report (undated) following the conclusion of the inquest touching upon the death of Mr Kenneth Perkins on 28 April 2022. This is a joint response to the Regulation 28 report prepared by UDHB and OCHS. UHDB received a copy of the Regulation 28 report on 29 June 2022. OCHS were first notified of the Regulation 28 report on 19 July 2022 following contact from UHDB. During the inquest you identified concerns with the process of information sharing between care providers on transfer. Further evidence was submitted by both Trusts before the fina l hearing on 28 April 2022. UHDB were advised that no witnesses were required to attend on 28 April 2022, and OCHS were not aware of the final hearing date and were unrepresented. The Coroner's concerns are noted as follows in the Regulation 28 report: Mr Perkins was transferred from 1/keston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls. The Royal Derby Hospital did not (but should have) requested a transfer document from 1/keston. That history would have allowed an enhanced level of care and obseNation to be put in place so as to prevent further falls. Community to acute hospital transfer Chair: www.uhdb.nhs.uk Follow us on Twitter @UHDBTrust Interim Chief Executive. Please visit www.uhdb.nhs.uk for the latest advice on attending our hospitals during COVID-19. OCHS response: In line with the evidence already submitted to the Court, DHCS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for OCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins. In cases involving an emergency transfer, a Nurse on the Ward will complete a SBAR form (Situation, Background, Assessment, Recommendation ). The SBAR form is a nationally recognised, easy to use, structured form of communication that enables information to be transferred accurately between individuals. The SBAR consists of standardised prompt questions in four sections to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition and the likelihood for errors. As the structure is shared, it also helps staff anticipate the information needed by colleagues and encourages assessment skills. Using SBAR prompts staff to formulate information with the right level of detail. The four sections are: • Situation - what the Nurse has found i.e., a patient with a suspected stroke. • Background - Medical History, dates of admission reason for admission to ward. • Assessment-Observations, what the Nurse believes the problem to be. • Recommendation - what course of action has been decided on, for example transfer to Hospital. The policy and process are well embedded within OCHS and we are not aware of any incidents or complaints relating to patients being transferred to an Acute Hospital without the appropriate documentation or medication. UHDB response: UHOB received an SBAR handover from staff at llkeston Community Hospital. Matron Campbell confirmed this in her supplemental report and explained that under risk factors the following is documented: under the moving and handling 'WZF plus 1 (wheeled zimmer frame and the assistance of 1 member of staff)" and under additional information "falls - high risk". The information from the transferring care provider is taken into consideration by the Trust, but it is not decisive. On admission to the Trust staff should complete further assessments to assess the patient's abilities and needs at that specific time, including mental capacity and falls risk assessment. If the transferring care provider sends no information on transfer, the expectation is that nursing staff at UHDB will telephone the care provider to obtain update to date information confirmed that this is well embedded into practice at the about the patient. Matron Trust. As UHDB received a completed form detailing mobility and fa lls risk, there was no indication to contact ICH for further information. Developments in information sharing Updated transfer documentation at UDHB UHDB had already identified the need to strengthen and reinforce accurate and timely communication on transfer of patients. UHDB already had a SBAR form used for transferring patients within site (completed electronically) on extramed ) and out to community sites (paper based) (appendix 1 ), this has been in place on the Derby sites since 2015 and was implemented across Burton sites in November 2021. A further form the STOP Safe Transfer of the Patient Tool (appendix 2) has been developed for acute to acute ambulance hospital transfers and was introduced in November 2021 . This form is mainly used for transfers between Emergency Departments and high dependency areas (respiratory and renal). Cascade training in these areas was used to support implementation. Derbyshire Shared Care Record In order to better improve the sharing of information about Patients in Derbyshire the Integrated Care System (Joined Up Care Derbyshire) developed the Derbyshire Shared Care Record. This became operational in December 2021. It means that health and social care professionals working across all Derby and Derbyshire's NHS and local authority organisations are able to access the same, appropriate information to support their care of individual patients. This is completely confidential and secure and is designed to help doctors, nurses and other health and social care professionals directly involved in a patient or client's care to make better, safer decisions. All Joined Up Care Derbyshire health and social care organisations are participating in the Derbyshire Shared Care Record. This includes both OCHS and UHDB. Please do not hesitate to let us know if you require any further information. We are satisfied that appropriate processes are in place to support information sharing between care providers. Best wishes Interim Chief Executive Chief Executive
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