Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0128, written 20 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Apr 2023 |
|---|---|
| Reference | 2023-0128 |
| Deceased | Joseph Maunick |
| Coroner | Peter Taheri |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | West Suffolk NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 The Right Honourable Steve Barclay MP Secretary of State for Health and Social Care 39 Victoria Street London SW1H 0EU 2 Mrs Amanda Pritchard Chief Executive for NHS England PO Box 16738 Redditch B97 9PT 1 CORONER I am Peter TAHERI, Assistant Coroner for the coroner area of Suffolk 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 18th March 2022 an investigation was commenced into the death of Joseph Willy Maunick. The investigation concluded at the end of the inquest on 18th April 2023. The narrative conclusion of the inquest was that: Joseph Willy Maunick (Will) died on 15th March 2022 as a result of a severe head injury that he suffered in a fall in the Emergency Department of West Suffolk Hospital on 4th March 2022. He was in the Emergency Department as a social admission, while his wife was going through unplanned emergency major surgery. Will was not safe to be left alone at home and required care around the clock. Exhaustive efforts to find appropriate care while his wife was in hospital were unsuccessful, so he had been admitted to a hospital Emergency Department as a last resort. This was not the most suitable environment for a gentleman with dementia who was a falls risk and required constant supervision. The situation was exacerbated by pre-existing severe pressures on the Emergency Department on that day due to high demand for beds, without the availability of beds to meet the demand, and a severe deficiency of staff. The scarcity of resource, relative to demand, at the hospital also contributed to Will not being transferred to a ward sooner. While there was no specific failure by an individual that contributed to the death, Will’s death was contributed to by the lack of availability of more appropriate care. The medical cause of death was confirmed as: 1(a) Subdural Haematoma Regulation 28 – After Inquest Document Template Updated 30/07/2021 1(b) Fall 2 Dementia, Complete Heart Block, Frailty 4 CIRCUMSTANCES OF THE DEATH Joseph Willy Maunick (Will) was an intelligent man, gifted with communication skills, who worked as a teacher and spoke multiple languages. In his later years he developed cognitive impairment, which in turn led to him being at very high risk of falls. This risk, in relation to which he needed constant supervision, was known to those caring for him and to those responsible for looking after him when he was admitted to the Emergency Department of the West Suffolk Hospital on 4th March 2022. He was admitted to the hospital Emergency Department not because he himself was experiencing a medical emergency, but as a last resort after exhaustive efforts to explore all options before Will was admitted to hospital: it proved not to be possible to find suitable alternative care for him in residential care placements while his wife, and main carer, underwent unplanned emergency major surgery. The inquest heard evidence that, prior to his admission to hospital, at least eight social care providers were contacted plus further residential homes, but none of them could provide emergency care for Will. The inquest heard undisputed evidence that this was an instance of a national care shortage. The inquest heard evidence that in an Emergency Department where many patients are suffering medical emergencies constant one-to-one supervision will not always be possible. I found as a fact that it was not possible on this occasion and that Will’s fall in the Emergency Department took place when the nursing assistant who was trying to maintain constant one-to-one supervision of Will insofar as possible had their attention momentarily diverted to another patient experiencing a medical emergency. I judged that it would not be just to describe this as a failure on the part of the nursing assistant or the Emergency Department staff. The reason why it was not an individual failure included that the inquest heard evidence that the hospital, and in particular the Emergency Department, was experiencing significant pressures associated with high demand and an internal critical incident had been declared. There was a high demand for beds within the hospital without the availability of beds to meet the demand. This included the facts that there were, at the time of Will’s arrival in the Emergency Department, 50 patients in the Emergency Department, of whom 32 were waiting for bed placement. Moreover, staffing was at a ‘black status’ (the worst level) across the hospital, with a deficiency of staff of around 60 nurses and nursing assistants. I found as a fact that those severe pressures – the high demand levels and the deficiency of staff and scarcity of resource – contributed to the death. Firstly, if it had been possible to care for and supervise Will on a constant basis as he needed, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. Secondly, on the balance of probabilities, the scarcity of resource relative to demand contributed to Will not being transferred to a ward – or other more appropriate environment – sooner. Apart from the inherent particular difficulties in providing constant supervision in an Emergency Department referred to above, the inquest also received undisputed evidence that the environment of a busy, noisy Emergency Department, with lights on at all hours of the day and night would be overly stimulating and not the most suitable environment for someone with cognitive impairment who was experiencing confusion and agitation. I found that such an environment probably contributed to Will’s inclination to wander and so to his fall. If it had been possible to transfer Will to a more suitable environment sooner, then on the Regulation 28 – After Inquest Document Template Updated 30/07/2021 balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. I found as a fact that, on the balance of probabilities, the lack of availability of more appropriate care contributed to the death. 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) A national care shortage contributed to a situation where a gentleman who was not experiencing a medical emergency, but who required constant supervision for his own safety in view of his cognitive impairment and very high falls risk, could not be cared for anywhere other than in a hospital Emergency Department. If there is not sufficient provision of care, including residential care placements, such that those in similar need do not receive suitable care, then circumstances creating a risk of future deaths will occur or continue to exist in the future, when they are placed in an environment that is not realistically able to provide the constant supervision needed, as occurred in this case. 2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff. In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department, and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment, where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you and / or your organisations 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 15 June 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: - - West Suffolk NHS Foundation Trust - - Norfolk County Council Norfolk & Suffolk NHS Foundation Trust Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 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: 20/04/2023 Peter TAHERI Assistant Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
From Minister Helen Whately
Minister of State for Social Care
39 Victoria Street
London
SW1H 0EU
Mr Peter Taheri
The Coroners Court and Offices
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
17 June 2024
Dear Peter,
Thank you for your letter of 20th April 2023 about the death of Mr Joseph Willy Maunick. I am
replying as Minister with responsibility for adult social care.
Firstly, I would like to say how saddened I was to read of the circumstances of Joseph’s death,
and I offer my sincere condolences to their family and loved ones. The circumstances your
report describes are very concerning and I am grateful to you for bringing these matters to my
attention. Please accept my sincere apologies for the significant delay in responding to this
matter.
I am aware that
the National Medical Director of NHS England,
has responded in detail to the serious concerns you have raised regarding the national severe
resourcing pressures in emergency departments (ED).
The report highlights pressures within EDs that continue to be monitored by the Trust. The
Care Quality Commission (CQC) were also made aware of the report following the incident.
Resourcing of ED services and others across the country is a known risk and is subject to
ongoing monitoring through engagement with the Trust. More broadly, CQC continues to
monitor waiting times and other national targets. They also carry out inspections of urgent and
emergency services in trusts that are performing poorly in line with national ED targets as part
of the current risk-based inspection model.
With regard to your concern about a potential national care shortage and insufficient provision
of care, including residential care placements, under the Care Act, local authorities are tasked
with the duty to shape their care market to ensure a diverse range of high quality, sustainable,
person-centred care and support services are provided.
A duty on the Care Quality Commission (CQC) to assess LAs’ delivery of their adult social
care duties went live on 1 April 2023 and the roll out of formal assessments to all 153 local
1
authorities commenced in December 2023. If CQC identify a serious failure, new powers
would allow the Secretary of State to intervene to drive improvement.
Last year, £16m was provided to partners to make support available including a focus on how
local authorities commission the right kind of care to meet the needs of everyone who draws
on care and support. Secretary of State powers also require adult social care providers to
share their data with us to allow for more awareness and insight on what is happening locally
and nationally.
Thank you for bringing these concerns to my attention.
Helen Whately
The Coroners Court and offices
Beacon House
Whitehouse Road
Ipswich
IP1 5PB
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
12 June 2023
Re: Regulation 28 Report to Prevent Future Deaths – Mr Joseph Willy Maunick
(Will) who died on 15 March 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 April
2023 concerning the death of Mr Joseph Willy Maunick (“Will”) on 15 March 2022. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Will’s family and loved ones. NHS England are keen
to assure the family and the coroner that the concerns raised about Will’s care have
been listened to and reflected upon.
The first concern you raised related to a national social care shortage, and the impact
this has had on the quality of care provided to Will. The Department of Health and
Social Care (DHSC) are best placed to comment on this issue as they hold
responsibility for social care provision. The DHSC have committed to adult social care
reform and have committed £700 million to transform and improve the adult social care
system in England, to include around access to support and joining up of services as
part of their ‘People at the Heart of Care’ plan.
Your second concern highlighted the severe pressures being placed on West Suffolk
Hospital, including its Emergency Department (ED), and the significant impact on
resourcing this was having. Your Report concludes that Will was not able to receive
the supervision he required or be transferred to a more appropriate ward at an earlier
opportunity.
We have engaged with West Suffolk NHS Foundation Trust regarding Will’s care on
his admission to the ED as a social admission on 4 March 2022, while diagnosed with
dementia and at risk of falls. At the time of Will’s admission, the Trust was operating
under an internal critical incident, due to a lack of flow and shortage of available beds.
As a result of these pressures Will was in the ED for a total of 15.5 hours. It is
documented that he fell in the ED despite receiving 1:1 supervision at the time of his
fall which resulted in a left subdural haematoma which he did not recover from. He
received palliative care until he passed away on 15 March 2022.
Actions have now been taken locally to minimise the risk of such an incident from
happening again at the Trust. These actions include:
- The Trust plan to share a report with the Integrated Care Board (ICB) Quality
and Safety Teams to raise awareness of available community resources. This
will align with reducing the lack of available resource/facilities in the community
to provide emergency placement/respite resulting in an avoidable hospital
admission.
- A review will be undertaken with ED staff to support the development of
appropriate pathways for vulnerable patients suffering with conditions such as
dementia and those at high risk of falls to ensure support is available in making
clinical decisions and ability to escalate a patient as a priority for a ward bed.
- A pilot of a quality improvement project within the ED will be undertaken to raise
awareness of high risk falls patients and a thematic review of falls within the ED
will also be undertaken. This will identify any wider themes and areas for further
learning and improvement. The Trust will also ensure that assistive technology
is available to staff to support in identifying when a patient is mobilising.
In January 2023, the Delivery plan for recovering urgent and emergency care services
was published by NHS England, which sets out the steps that the NHS are taking to
respond to the demand being placed on urgent and emergency care (UEC) services
at a national level. The plan also includes details for the expansion of community
services including more joined-up care for older people living with frailty, including
scaling up urgent community response, frailty and falls services across the whole
country – meaning the right people delivering the right care and avoiding admission to
hospital where it’s not necessary. We will also work with Integrated Care Systems
(ICSs) to provide streamlined pathways for older adults, including people with
dementia. Falls are the number one single reason why older people are taken to the
emergency department, and around 30% of people aged 65 and over will fall at least
once a year.
It is one of the core objectives of NHS England’s 2023/24 Operational Planning
Guidance to improve retention and staff attendance, through a systematic focus on all
elements of the NHS People Promise. This includes taking advantage of opportunities
to deploy staff more flexibly, improving staff experience and increasing productivity.
Nationally, there are also clear requirements placed on NHS Trusts to ensure that the
right skill mix of medics and other professional groups are in place to respond to the
anticipated demand throughout a day.
I would also like to provide further assurances on national NHSE work taking place
around the Reports to Prevent Future Deaths. All reports received are discussed by
the Regulation 28 Working Group, comprising Regional Medical Directors, and other
clinical and quality colleagues from across the regions. This ensures that key learnings
and insights around preventable deaths are shared across the NHS at both a national
and regional level and helps us pay close attention to any emerging trends that may
require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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