Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2023-0008, written 31 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 | 31 Dec 2022 |
|---|---|
| Reference | 2023-0008 |
| Deceased | Anthony Blower |
| Coroner | Robert Simpson |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Portsmouth Hospitals University NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
t.•1:bj Portsmouth Hospitals University NHS Trust Corporate Nursing De La Court House Queen Alexandra Hospital Southwick Hill Road Cosham, Portsmouth Hampshire P06 3LY 20/12/2022 Mr R Simpson Assistant Coroner HM Coroners' Office Coroners Court 1 Guildhall Square Portsmouth PO1 2AJ Dear Mr Simpson I write further to the inquest into the death of Mr Anthony David Blower which was concluded on 8th December. I understand from our Head of Legal Services that you had 2 main concerns which were leading you to consider whether or not it is necessary to issue a Prevention of Future Deaths reports. I will set out the 2 concerns below, as I understand them, with my response to those issues after each one. 1. You were concerned that you had seen evidence of poor completion of care plans. I understand that at the inquest one of the witnesses gave evidence that there has been continued training and education within the trust on the importance of the completion of nursing documentation but that she also gave evidence that the quality of the completion of care plans remains variable. You accept that staffing levels are challenging but you are concerned that there didn't appear to be any auditing of care plans/ support to help nurses ensure that care plans are properly completed. The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways. (I) One such system is the Ward Accreditation process which incorporates a review of patient records as well as observations of care delivery. Currently 24 of the wards have been audited in this way, with 14 left to be reviewed. During the ward accreditation process the team, currently consisting of a Senior Matron, a Senior Sister and two volunteers, visit the ward on several occasions at different times of the day. During these visits they speak to staff, patients and visitors and observe the care that patients are receiving as well as the processes that are in place on the ward. Ten patients and their families are asked about the care they receive, including whether they receive enough help with meals, and what they feel is Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 r~1:1;1 Portsmouth Hospitals University NHS Trust done well at PHU and if there was anything they could identify that could be improved. Staff are asked to describe the nutritional requirements for their patients and to evidence what food and fluids their patients have received in the last 24 hours. Staff are asked about which patients they consider to be most at risk of falls and acquiring a pressure ulcer, why they consider them to be high risk and to describe the plan of care that they are currently receiving. The Ward Accreditation team review the end of bed documentation and care plan to see if the plan described matches the documentation and the findings are discussed with the staff caring for the patient. Each question is asked five times to five different nurses however these questions are asked to different nurses on different days and not every nurse is asked each question, so several patients are discussed during the period of the assessment. At least one safety huddle is attended in each area and further information is requested if necessary, particularly around the plan of care for identified risk factors. Any immediate concerns highlighted are shared with the Nurse in Charge on that shift and the Senior Sister/Senior Charge Nurse when they are next on duty. The results of the review are documented in a comprehensive feedback report. This is shared with the Senior Sister/ Senior Charge Nurse and Matron, ideally within 1-2 weeks following completion of the visit. The Senior Sister/Senior Charge Nurse is asked to complete an action plan, initially starting with the top three things that will make a difference to staff and patients. When reviews of all the in-patient wards within a Care Group are completed, the results are shared with the Divisional Triumvirate and Ward Accreditation is added as a regular item at their Monthly Divisional Governance meetings. A monthly report is provided to the Professional Board (which is chaired by the Chief Nurse and represents Nursing, Midwifery and Allied Health Professionals). If another area of concern has been identified a report is submitted to the Trust lead so that appropriate quality improvement actions can be considered and taken. All wards will have ward accreditation assessments repeated and a scoring system will be in place for the second round of assessments which will rate the wards as Outstanding, Great, Good or Working towards Accreditation. Their rating will then determine how regularly they are reviewed, which will be at a 6 monthly interval initially. ii) During the pandemic there was a direction from NHS England that participation in national clinical audits should be suspended to enable prioritisation of the Trust's response to COVI D-19. As normal service returns, priority areas requiring audit are constantly being reviewed. The current Trust plan prioritises participation in 'must do' national clinical audits covering Cancer, Respiratory, Cardiac and Inpatient Falls. There are approximately 50 plus national clinical audits requiring data collection and completion, although resource capacity is very limited. Local audit activity is led at an individual specialty level. There are currently over 500 individual clinical audit projects on the Trust wide audit plan including Pressure Ulcer Risk Assessments - Purpose T Documentation Audit, Nursing documentation and Falls Prevention. iii) As you may be aware, the trust is currently transitioning towards an electronic solution for clinical notes (digital forms) which will enable an improvement in the completion of key mandated fields. This will be about 3-6 months in the decision- Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986 r~1:b1 Portsmouth Hospitals University NH S Trust making process then progressive work over an estimated 2 years after this if it is decided that an 'all in one' solution is to be purchased. The trust is also currently implementing an electronic prescribing and medicines administration system Trust wide. The digimed Electronic Prescribing and Medicines Administration (EPMA) system will be fully deployed trust wide by June 2023 and this will enable routine audits to be completed and reported on detailing the reliability of prescribing and administering nutritional supplements to Inpatients. 2. understand that at the inquest you heard evidence about the difficulties of ensuring that those patients who do not have fluid charts are offered 7 drinks a day and that nurses try and keep an eye on water jugs, etc. I understand you were concerned that no one has overall responsibility for monitoring of fluids for those patients without fluid charts. Food and Nutrition is a Care Quality Commission fundamental standard and is part of the National Patient Safety Agency agenda. Nutrition and Hydration needs are recognised as being key to our patients' recovery and is the responsibility of all our staff. However, as you are aware not all patients have fluid and nutrition charts, only those for whom poor nutrition/hydration has been flagged as a particular concern either from a medical or nursing perspective. There are some clear indicators of when to chart food and fluid intake: unintentional weight loss, depression or low mood, inactivity and loss of appetite, nausea and gastrointestinal symptoms are obvious ones. There are also some wards where this is more routine than others depending on their specialty of care and in some wards it is clinically indicated for every patient to be on a food and fluid chart. We expect registered nurses to use their clinical expertise, observe the patient's mucous membranes, capillary refill time, blood pressure, pulse and weight to take a view on whether the patient is drinking and eating sufficiently. Conversation with the patient, their next of kin, as well as reviewing their risk of Malnutrition (MUST 5 step screening tool is used to identify patients at risk of malnutrition) will indicate whether the patient has a good appetite and stable weight. The multi-disciplinary workforce also observe the patient's mood and activity at mealtimes, HCSWs and housekeepers will notice and document if a meal has been untouched, relatives will speak to staff and ask if they can bring in snacks to tempt their loved one. In short, whilst nurses do try and monitor fluid intake from water jugs, this is only one of a number of monitoring tools. In addition, we do audit the completion of nutritional assessments within 1 day of admission and attached is the data from the latest audit which demonstrates that the vast majority of patients do have their risk of malnutrition assessed within the first day of admission. One approach that we have deployed since the pandemic is the addition of mealtime volunteers. These specialised volunteers receive additional training to support frail patients to access their meals whilst they are hot and talk to them so that they have a social experience during mealtimes. A small number of Dementia volunteers have also been recruited and trained to provide additional support with engaging confused and vulnerable patients at mealtimes in an attempt to help them maintain interest and tempt them to eat throughout mealtimes. Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, P06 3LY Registered charity number: 1047986 r.•1:kj Portsmouth Hospitals University NHS Trust The Trust is also planning to reinstate the nutritional committee in the New Year, which I will attend in my capacity as the Deputy Director of Nursing for Quality and Safety, this forum will provide a senior focus to ensure that wards are protecting mealtimes so that patients are not interrupted or undergoing examinations/ investigations during mealtimes. There will be a multidisciplinary membership for the committee, and we will be challenging ourselves to ensure that we are monitoring our performance in this fundamental area of care and exploring as many opportunities as possible to improve the nutritional status of our patients. Other Trusts have introduced finger food menus and innovative schemes to enhance access to out of hours provision of meals and this will be included within the review of how nutrition and hydration standards can be improved for our patients at PHU. I do hope the contents of this letter provide you, and Mr Blower's family with the assurance that both the completion and auditing of nursing documentation (including care plans) and the careful monitoring of fluid (and nutritional) intake are key priorities for the Trust that are already being implemented. However, if you have any further questions, please do not hesitate to contact me. Yours sincerely Deputy Director of Nursing for Quality and Safety Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986
r~1:b1 Portsmouth Hospitals University NHS Trust Trust Headquarters F Level, Queen Alexandra Hospital Southwick Hill Road Cosham PORTSMOUTH,P063LY 21 st February 2023 Mr R Simpson Assistant Coroner HM Coroner's Office Coroner's Court 1 Guildhall Square Portsmouth P01 2AJ Dear Mr Simpson Response to Regulation 28 report to prevent future deaths following the inquest into the death of Anthony Blower I write to provide the Trust's response to the regulation 28 report issued following the inquest into the death of Anthony Blower. For ease of reference the matters of concern identified by you during the inquest, as described in the report, are set out below in italics with the Trust's response underneath each concern. 1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower's arrival on the ward, had been updated during his stay. I heard evidence that there were changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments. The multi factorial falls risk assessment had not been fully completed on admission nor fully updated after an in-patient fall by Mr Blower. The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes. I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that concordance with documentation remained poor. The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority. Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, P063LY Registered charity number: 1047986 Worki~ To drive excellence in care for together our patients and communities r~1:b1 Portsmouth Hospitals University NHS Trust Trust Response Good documentation is vital to the provision of good quality clinical care as you acknowledge above, and as is explained in the letter of 20th December 2022, (attached) the Trust does audit documentation and is in the process of updating its systems. The importance of good documentation is reflected in our training for both medical and nursing staff. With regard to medical staff this is reinforced through ward-based scrutiny. With regard to nursing staff, the trust has recently reviewed its preceptorship programme for all newly registered nursing staff and for the new HCSW workforce. This includes a comprehensive overview of documentation as part of a fundamentals of care education package. The current hybrid between paper and electronic records on the wards creates greater complexity and inefficiency for our staff in terms of recording information. It also leads to there being a more fragmented overall record which makes it harder for members of the multidisciplinary team to be aware of all the information that has been recorded for any given patient. The ambition of PHU and similar NHS Trusts who have not already done so, is to move to a true paper free Electronic Patient Record (EPA). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time. 2) Mr Blower was found to be dehydrated and he required IV fluids during his admission. The hospital nutrition policy (section entitled hydration) states that it is the responsibility of the registered nurse and medical practitioner to ensure patients receive adequate fluids and that a minimum of 7 drinks should be provided daily. In evidence I was informed that the nurses monitor fluid intake by keeping an eye on water levels in patients' jugs (for those not deemed to require fluid intake charts). There is no one on a ward with overall responsibility for ensuring that the trust policy on hydration is adhered to. Representations from the hospital state that other members of staff also keep an eye on nutrition. This was not sufficient to prevent Mr Blower from becoming seriously dehydrated. Trust Response Inpatients are routinely offered a drink at 7 scheduled beverage rounds a day, 6 of these are carried out by housekeeping staff with the final nighttime round being carried out by ward nursing staff. In addition, water jugs are provided for all patients which are refreshed throughout the day as required and should be checked/topped up by housekeeping staff at mealtimes. Additional beverages are also available throughout the day via ward staff, who will contact a housekeeper or access the beverage trolley overnight. We do not routinely keep a fluid balance record for patients who are drinking well and not receiving supplementary fluids. Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, P06 3LY Registered charity number: 1047986 Worki~ To drive excellence in care for together our patients and com munities r~1:bj Portsmouth Hospitals University NHS Trust Where there is a clinical need, for example in patients with sepsis, acute kidney injury, diarrhoea and vomiting, patients will receive intravenous fluids, and for those patients fluid balance charts will be kept. The Trust recognises the importance of having a Nutrition and Hydration strategy to support clearer guidance on decision making around which risk factors should lead to a patient being placed on a fluid balance chart. We have just re-established the Trust's Nutrition and Hydration Steering Group which has been tasked with updating that strategy. I do hope the contents of this letter provide the assurance required to demonstrate that the Trust is aware of, and responding to, those issues of concern raised in the regulation 28 report. If you, or any of your Coronial colleagues, would like to visit Queen Alexandra Hospital to see how documentation is completed and audited, and how hydration is administered and monitored, we would be delighted to facilitate that. Yours sincerely Chief Executive Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, P06 3LY Registered charity number: 1047986 Workir-g To drive excellence in care f or together our patients and communities
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 Chief Coroner - PFD Reports 2 3 1 CORONER I am Robert SIMPSON, Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 03 November 2020 I commenced an investigation into the death of Anthony David BLOWER aged 83. The investigation concluded at the end of the inquest on 08 December 2022. The conclusion of the inquest was that: On the 25th October 2020 Anthony David Blower died at his home address in Sussex Road, Petersfield. He had sustained a number of falls in September 2020, was admitted to hospital and diagnosed with bilateral subdural haematoma. He underwent burr hole surgery on the 26th September 2020. Mr Blower was transferred to Queen Alexandra Hospital on the 13th October 2020 and found on the floor next to his bed at 21.00 on the 14th October 2020, on the 20th and 21st October 2020 his condition declined significantly . A CT scan revealed further bleeding, Mr Blower did not undergo further surgery and received palliative care. 4 CIRCUMSTANCES OF THE DEATH The deceased died following a fall which caused an initial bleed affecting his brain. He suffered from pre-existing cardiac conditions and cerebral amyloid angiopathy which may have contributed to the initial fall and the bleeds to his brain. The impact of his age and multiple medical conditions complicated his treatment and impacted recovery. 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) 1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay. I heard evidence that there were changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments. The multi factorial falls risk assessment had not been fully completed on admission nor fully Regulation 28 – After Inquest Document Template Updated 30/07/2021 updated after an in-patient fall by Mr Blower. The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes. I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that concordance with documentation remained poor. The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority. 2) Mr Blower was found to be dehydrated and he required IV fluids during his admission. The hospital nutrition policy (section entitled hydration) states that it is the responsibility of the registered nurse and medical practitioner to ensure patients receive adequate fluids and that a minimum of 7 drinks should be provided daily. In evidence I was informed that the nurses monitor fluid intake by keeping an eye on water levels in patients’ jugs (for those not deemed to require fluid intake charts). There is no- one on a ward with overall responsibility for ensuring that the trust policy on hydration is adhered to. Representations from the hospital state that other members of staff also keep an eye on nutrition. This was not sufficient to prevent Mr Blower from becoming seriously dehydrated. 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 February 25, 2023. 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 I have also sent it to 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 31/12/2022 Robert SIMPSON Assistant Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
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