Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0045, written 2 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2023 |
|---|---|
| Reference | 2023-0045 |
| Deceased | Mary White |
| Coroner | Naomi Rees |
| Coroner area | Gwent |
| Category | Wales prevention of future deaths reports (2019 onwards) · 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.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CORONER I am, Naomi Rees Former Assistant 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 an investigation was opened on 22 June 2021 into the death of Mary Doreen White The investigation concluded at the end of the inquest on: 5 July 2022 The conclusion of the inquest was recorded as: Accident The medical cause of death was: 1 a Chest Infection b Osteoporotic fracture of right neck of femur (operated) and Chronic Obstructive Pulmonary disease II. Frailty of Old Age CIRCUMSTANCES OF THE DEATH Mrs White was a lady of advancing years, who had a number of increasing health concerns. She was admitted into Ysbyty Ystrad Fawr on 5 April 2021. Whilst she was an inpatient she had three falls. The first fall caused superficial head injury, the second fall caused a right fractured neck of femur and the third caused Mrs White to suffer a moderately displaced intertrochanteric fracture of the right proximal femur. Following the third fall she underwent surgery at the Grange University Hospital but when recovering from that surgery her condition deteriorated and she died. Box 3 of the Record of Inquest reads: Mary Doreen White was admitted to hospital in April 2021. She fell in hospital and suffered traumatic injury which required surgery. Whilst recovering she developed a chest infection from which she could not recover. Her condition deteriorated and she died on 9 July 2021 at Ysbyty Ystrad Fawr. 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: - Evidence received during the investigation and inquest (and corroborated by the family) demonstrated that nursing staff were trying to manage and care for patients in the very best way that they could. However, they were hampered in their efforts for the following reasons: 1. Despite requesting additional nursing staff, the Bargeod ward was short-staffed when Mrs White fell. There did not appear to be any documented plan or procedure in place for how patients would be safely managed when it was not possible (because of staff shortage) to carry out the level of care for individual patients that they had been assessed as requiring. 2. The ward is L-shaped and the patients on the ward are managed in individual cubicles. Mrs White should have been in view of nursing staff as part of her Level 4 enhanced care (‘observation of cohorted patients’). However, it was not possible to provide the observations that Mrs White required because: a. Patients were inside cubicles and therefore out of sight of staff and, b. The ward itself was L-shaped. 3. The Bargoed ward is a stroke ward and one where it is usual to see patients who have a high risk of falls and mobility difficulties. Prior to Covid-19 it was explained that staff would take patients who required the Enhanced Care to the dayroom so that they could be under the required observation. Since Covid-19, this had not been possible. To counteract the logistical difficulties faced by staff in observation of Enhanced Care patients on the ward it was explained that patients are now moved to their cubicle doorway for periods of the day so that they are in sight of nursing staff. This appeared to be ineffective because: a. The particular care needs/wishes of a patient may mean that is not suitable. b. That only accounts for part of the day. 4. To further counteract the difficulties with observing patients on Enhanced Level 4 care it was explained that clip-on alarm sensors were used. There was evidence given that patients are able to simply unclip these sensors, rendering the system ineffective. A Falls Review Panel had noted that Providing Level 4 Enhanced Care on this ward was extremely challenging and that quality care at Level 4 was unachievable in a single room environment. It was noted that the Corporate Nursing Team had reviewed the Enhanced Care Policy in light of the fact it did not fit single room environment, however at the time of the inquest it did not appear from evidence received that a further plan to manage Level 4 patients on this ward had been made and/or communicated to staff. 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. • Confirm whether any investigation and/or steps have or will be taken to address the difficulties encountered with staffing and observation and care of 7 8 9 Enhanced Level 4 Patients on single unit wards (particularly on Bargoed Ward, where Mrs White was cared for). YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 01 April 2023. The Senior Coroner for Gwent (Caroline Saunders), 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 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Mrs White 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. DATE 2 February 2023 Signed: Naomi Rees Former Assistant 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.
27th March 2023
Private & Confidential
Caroline Saunders
Senior Coroner (Gwent)
Dear Ms Saunders
Re: Aneurin Bevan University Health Board response to Regulation
28 Report received following the inquest touching on the death of
Mary Doreen White
I am writing to provide you with the Health Board’s response to the
Regulation 28 Report to Prevent Future Deaths, following the inquest into
the death of Mary Doreen White.
As requested, the information presented below is intended to describe the
action taken / being taken to mitigate the risk of future deaths.
The Health Board fully accepts that protecting in-patients from falls and the
related harm is the responsibility of the entire multidisciplinary team. This is
extensively supported by the evidence base and national guidance, which
the Health Board both endorses and works to incorporate in its approach to
protecting patients whilst in hospital.
Matter of Concern 1– Staffing
As you state, despite taking all reasonable steps to secure the required
nurse staffing levels, Bargoed Ward had a deficit in their staffing numbers
when Mrs White fell. Additional staffing was secured however there
remained a shortfall of 1 HCSW. The Health Boards expectation is that on
occasions where the required staffing levels cannot be met, this deficit is to
Bwrdd Iechyd Prifysgol Aneurin Bevan
Pencadlys,
Ysbyty Sant Cadog
Ffordd Y Lodj
Caerllion
Casnewydd
De Cymru NP18 3XQ
Ffôn: 01633 436700
E-bost: abhb.enquiries@wales.nhs.uk
Aneurin Bevan University Health Board
Headquarters
St Cadoc’s Hospital
Lodge Road
Caerleon
Newport
South Wales NP18 3XQ
Tel No: 01633 436700
Email: abhb.enquiries@wales.nhs.uk
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
be reported using the RL Datix reporting system and the appropriate
escalation to the senior nursing team should occur. The risks associated with
staff shortages are then reviewed by the senior nursing team, and actions
taken to minimise harm. This includes; prioritising duties for that shift,
reviewing staffing across the site and reviewing the needs of patients and
deploying staff appropriately. Patients identified as enhanced observation
requiring 1:1 supervision should be prioritised when allocating staff to
ensure appropriate observation and patient care.
The Health Board has a ratified escalation framework which clearly
articulates the process to follow in incidents whereby there are staffing
deficits that despite best efforts have not been rectified. This framework
describes everyone’s responsibility in maintaining appropriate and safe nurse
staffing levels and sets out clear actions if there is a deviation from what is
required. Additionally, daily site meetings occur to review nurse staffing
levels, consider any deficits, manage and identify any potential risks and
escalate any requirements to the Resource Bank.
Bargoed ward comes under the remit of section 25B of Nurse Staffing Levels
(Wales) Act 2016 (NSLWA). In line with the requirements of the Act, an in-
depth bi-annual review is undertaken to determine acuity, dependency and
nurse staffing requirements. Quality indicators aligned to the NSLWA are
considered during the re-calculation, one of which is falls. The bi-annual
review involves the full engagement and contribution of the Assistant
Divisional Nurse, Senior Nurse, Ward Sister, finance and workforce to ensure
the ward establishment is appropriate to meet the needs of the patients. In
addition, the quality patient safety (QPS) team monitor the numbers of falls
across the Health Board and review any themes and learning.
Recruitment and retention have been challenging, especially during Covid.
The Health Board has recently promoted local recruitment events at all
enhanced Local General Hospitals (eLGH), including Ysbyty Ystrad Fawr,
(YYF) which were successful in recruiting to and above the healthcare
support worker establishment.
is envisaged that the successful
It
applicants will be in post by the end of April 2023.
Furthermore, the Health Board are introducing the Safecare Programme on
all wards under section 25B of the NSLWA. Safecare
is a national
programme currently being rolled out across all Health Boards in Wales. It
matches staffing levels to patient acuity, providing control and assurance
from bedside to board. It is designed to increase patient safety while
maintaining efficiency and enables informed decisions to be taken at various
levels of management.
Additionally, the Safecare system allows ward staff to complete a register of
staff in attendance shift by shift as well as undertaking an assessment of
patient acuity twice a day. Nursing teams are able to make professional
judgements on whether or not the staffing levels are appropriate to meet
the needs of the patients and raise red flags to record identified risks. The
system provides the senior nursing teams with instant access to ward level
2
data and a site wide view of staffing status, highlighting areas of concern to
the
enable effective and evidence-based decision making regarding
appropriate deployment of nursing staff to support patient safety.
Matter of Concern 2 – Environment
In YYF the ward configurations are L shaped and split by pods which are able
to accommodate 8 patients in single rooms, staff are usually allocated to a
pod. There are computers and notes available in all pods to ensure that
staff can remain in their designated areas whilst completing their nursing
duties.
The single room environment can be challenging when multiple patients
require an enhanced level of care. There is a requirement for staff to
carefully consider how individual patients needs can be met and formulate a
care plan outlining frequency of observation and level of care required. If a
patient is assessed as requiring enhanced observation with 1:1 supervision,
then staffing plans must reflect this. Additionally, if patients require
cohorting level of observation this can be met by using a cohorting approach
to meet care needs.
Where one to one supervision or cohort nursing is assessed as being
required the medical wards at YYF utilise the end pod. The ‘end pod’, has 8
beds with the smallest footprint. These areas tend to be the quietest areas
within the ward layout and is therefore effective in reducing over stimulation
due to constant noise and ward activity. Bargoed Ward ensures patients
requiring enhanced care are nursed in this area.
All current core staff on Bargoed Ward have undertaken training on the
Multi-Disciplinary Falls Risk Assessment via virtual classroom sessions and
there has also been on site training.
Matter of Concern 3- Use of Day Rooms
All wards have a day room area for patients, these are utilised to support
the use of meaningful activities. Since the reduction in Covid 19 cases this
area is often used during daytime hours to support the cohorting of patients
who require a higher level of supervision. However, there are instances
during extreme demand when the dayroom is unable to be used.
All wards on the YYF site have an activities box, supplied by the Patient
Centred Care team, access to interactive devices and projectors screens
have just been introduced. Volunteers have also restarted, therefore
facilitating activities and providing companionship to our patients has been
reintroduced.
Matter of Concern 4- Use of sensors
Sensors have the function to alert staff if a patient is attempting to stand or
get out of their bed. This will alert staff, who may not be in the immediate
3
area, that a patient is at risk of falls as they are attempting to mobilise.
Bargoed Ward does have some movement sensors in place for patients, for
whom they have assessed as suitable and appropriate.
Following discussion with the Assistant Director of Therapies and Health
Science, work has been undertaken nationally as to the effectiveness of
sensors in falls management. Information suggests that for the majority the
use of sensors may not be as effective as initially thought. This remains
under discussion by the ‘National Inpatients Falls Network’.
As a Health Board we need to collectively explore learning from the use of
sensors in the Care Homes setting and how this may translate into the
secondary care environment. There is also work ongoing at a national level
with Health and Safety, it is recognised that we need to understand the
national picture in adopting best practice and national learning.
To further support our response an action plan will be developed to capture
and monitor actions and will be shared at Falls and Bone Health Group by
the clinical team.
I trust that this information addresses the concerns raised in your report,
however, please do not hesitate to contact me should you require any
further information.
Yours sincerely
Prif Weithredwr/Chief Executive
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