Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0413, written 22 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Dec 2022 |
|---|---|
| Reference | 2022-0413 |
| Deceased | Glenys Phipps |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Director of Nurse and Health Professional Education, Health Education and Improvement Wales (HEIW)) 1 2 3 CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 5/10/2020 an investigation was opened into the death of Glenys Lillian Phipps The investigation concluded at the end of the inquest on: 8/12/2022 The conclusion of the inquest was recorded as: Death by Accident. The medical cause of death was: 1a Subdural haematoma 1b Fall 2. Advanced Vascular Dementia. Hip Fracture, CVA, Osteoarthritis, hypertension, Pancreatitis, gallstones, poor mobility 4 CIRCUMSTANCES OF THE DEATH Glenys Lillian Phipps was admitted to hospital on 3/9/2020 for investigations of abdominal pain. Glenys suffered with dementia and was confused in hospital. There was an inadequate assessment of her risk of falling and no personalised care plan was developed to reduce the risk. Glenys fell twice in hospital. The second fall on 17/9/20 resulted in a cerebral bleed. Her condition deteriorated thereafter, and Glenys died as a result of the head injury on 21/9/20 at Nevill Hall Hospital. 5 CORONER’S CONCERNS During the course of the inquest, 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: - I heard that a key component of the policy to minimize the risk of falls is a thorough understanding of the multifactorial risk assessment process (MFRA) Whilst I was informed that all adult nurses were made aware of the risk of falls during their nurse training, they are not trained in the use of the MFRA. It is clear that newly qualified nurses rapidly assume responsibility for the care of a group of patients, often before they can undertake the MFRA training. The senior nurse who gave evidence and presented the internal investigation into the circumstances surrounding Mrs Phipps’ death, undertaken by Aneurin Bevan University Health Board, confirmed that it would be beneficial to the safety of patients if MFRA processes were taught to student nurses prior to qualification. 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. I should be grateful if the following information be provided to me: In light of the evidence heard, the steps being taken by the training facilities to ensure that nurses are adequately trained in falls risk management prior to qualification. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely . I, the Coroner, may extend this 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 necessary 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Glenys Phipps Health Inspectorate Wales. 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 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 DATE: 22 December 2022 Signed Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
Addysg a Gwella Iechyd Cymru (AaGIC) Health Education and Improvement Wales (HEIW) Tyˆ Dysgu, Cefn Coed, Nantgarw CF15 7QQ Ffôn | Tel: 03300 585 005 Ebost | Email: heiw@wales.nhs.uk Gwefan | Web: aagic.gig.cymru / heiw.nhs.wales From: Director of Nurse and Health Professional Education Health Education and Improvement Wales (HEIW) CF15 7QQ To: Ms Caroline Saunders HM Senior Coroner of Gwent Room 204W The Civic Centre Godfrey Road Newport NP20 4 UR 21st February 2023. Dear Ms Saunders Re: Health Education and Improvement Wales response to Regulation 28 Report to Prevent Deaths, received following the Inquest touching on the death of Glenys Lillian Phipps. Thank you for your report dated 22 December 2022, which was received on 28th December 2022 following annual leave and Christmas Bank Holidays. Further to you report, the information presented below is intended to describe the action taken/being taken by Health Education and Improvement Wales (HEIW) to mitigate the risk of future deaths. Health Education and Improvement Wales (HEIW) is the strategic workforce and education body for NHS Wales and sits alongside Health Boards and Trusts. We are committed to delivering the vision of transforming the workforce for a healthier Wales and have a leading role in education, training, development and shaping the healthcare workforce in Wales to ensure high-quality care for the people of Wales Excellent education and training underpin the development of a sustainable workforce, which in turn provides the capacity and capability to lead and promote high quality, safe patient, person, and community centred care. In 2021, following extensive stakeholder engagement and researched international best practice, the HEIW Board approved and awarded healthcare education contracts, for delivery over next 10 years,. Alongside the NMC Standards framework for nursing and midwifery education. and Standards for student supervision and assessment, key themes were built into the contract specification to meet the future healthcare needs in Wales. Clinical placements and student supervision HEIW is committed through a programme approach to support the development of clinical placement availability and quality to underpin delivery of education and training across healthcare programmes. Placement learning constitutes a significant proportion of healthcare education and training in Wales, with over 11,000 students undertaking pre-registration education programmes at any one time. Increases in student and trainee numbers has placed a substantial premium on placement availability. Building on existing placement availability , new models for placement learning, inter-professional education and supervision; continue to be developed to meet the required quality benchmarks for placement excellence Pencadlys HEIW | HEIW Headquarters, Tyˆ Dysgu, Cefn Coed, Nantgarw CF15 7QQ Ffôn | Tel: 03300 585 005 Prior to attending their first clinical placement It is a contractual requirement with Universities for all student nurses to undertake a range of mandatory eLearning modules, which includes Moving and Handling and Falls Prevention. While on placement, the student is supported by a Practice Education Facilitator (PEF) funded by HEIW. PEF roles are multi-layered and span the whole student journey including involvement in selection and recruitment; facilitation of placement capacity, delivery of supervisor and assessor training, quality assurance of practice learning environments; and supporting registered staff with students who may not be meeting required levels of proficiency, through to the point of registration and support of new employees during their initial period of preceptorship. Positive feedback continues to be received from students, supervisors and assessors about the support provided by PEFs. Matter of concern – is it beneficial for Multifactorial Risk Assessment (MFRA) processes to be taught to student nurses prior to qualification? We fully accept that improving patient safety and protecting patients from Falls is the responsibility of the entire multidisciplinary team, both registered and non registered staff. This is fully supported by the evidence and national guidance With reference to the MFRA, this is a nationally agreed programme delivered by all Health Boards and Trusts across Wales. The MFRA is an assessment with multiple components that aims to identify a person’s risk factors for falling. It should be performed by a healthcare professional with appropriate skills and experience and should be part of an individualised multifactorial intervention which may need to be coordinated across different professionals and settings; to ensure the patient receives the appropriate safe care. While student nurses may be introduced and learn about the MFRA at various stages of practice placement under supervision, they cannot be held responsible to coordinate care. it is therefore not appropriate for MFRA education and training during their pre-registration education. I am pleased to report that Aneurin Bevan deliver MFRA education to all new registered nurses as part of their induction into the organisation and provide support to develop and enhance their skills . I would suggest the the lessons to be learned from this incident and the safety improvements introduced at Aneurin Bevan, be shared with other organisations. I trust the above addresses the concerns raised in your report. However, please do not hesitate to contact me should you require further information Your sincerely, Director of Nurse and Health Professional Education Health Education and Improvement Wales (HEIW) [Type here]
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