Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0267, written 19 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2023 |
|---|---|
| Reference | 2023-0267 |
| Deceased | Shane West |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath Port Talbot |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR 1 CORONER I am Aled Gruffydd, Assistant Coroner, for the coroner area of SWANSEA NEATH & PORT TALBOT 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 the 20th August 2018 I commenced an investigation into the death of Shane Luke West. The investigation concluded at the end of the inquest on the 19th July 2023. The medical cause of death is 1a) multi organ failure 1b} carfdio respiratory arrest 1c} abdominal distention caused by faecal impaction 2 sotos syndrome, scoliosis The conclusion of the inquest as to how Mr West came to his death was a narrative conclusion and is as follows:- The deceased died from multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention. The distension was caused by longstanding chronic constipation and fluid build up from his laxative treatment. 4 CIRCUMSTANCES OF THE DEATH The deceased was Shane Luke West and he was pronounced dead on the 1?'h August 2018 at Morriston Hospital, Swansea. The cause of death was multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention, which itself was caused by longstanding chronic constipation and fluid build up from his laxative treatment. Shane was admitted to Morriston Hospital on the 31 st of Julv 2018 with chronic constipation and abdominal swelling. The treatment plan was conservative consisting of laxatives, enemas and colonic irrigation. Shane also had SOTOS syndrome and suffered from a learning disability. The learning disabilities team of the Health Board were involved to allow Shane to understand the treatment being offered. It was noted that the extent of the constipation on admission was causing significant abdominal distention the result of which meant that Shane's abdomen was pushing his diaphragm up into the chest cavity thereby restricting his lung function. Shane underwent regular examinations with varying results. On some occasions his abdomen felt distended, and on others it felt soft and non tender, suggesting improvement. On the 16th of August 2018 Shane deteriorated with respiratory compromise. Shane underwent a colectomy and ileostomy formation to decompress the abdomen to allow effective mechanical ventilation. Whilst this procedure provided temporary improvement, Shane eventually declined further and passed away on the 1?tti of August 2018. 5 CORONER'S CONCERNS During the course of the inquest it transpired that the condition of Shane's abdomen was changeable. Shane's learning disability also meant that he was reluctant to report whether he was in any discomfort thus hiding the true picture. The cause of the variable abdomen condition was due to the osmotic laxative treatment filling the abdomen with fluid thus making it distended. Shane was prescribed three sachets of laxative in the morning and three in the evening. On the 15th of August there also appeared to be an instruction for an additional 8 sachets to be administered. The nursing notes state that these were not given due to a maximum of 8 sachets being allowed over a 24 hour period, but the PAN prescription chart appear to be signed as being given. It was not clear therefore whether additional sachets were administered. In any event Professor Colin Johnson acting as an independent expert witness stated that it was not the dosage that was relevant but at what frequency it was given, whether all together or staggered over 24 hours. It was found at inquest that the conservative method of treating the constipation was appropriate and there was insufficient evidence to state that excessive laxatives had been administered, however the combination of a longstanding constipation caused the abdomen to become distended and lose muscle mass meaning that it was inefficient at moving material along the gastro-intestinal tract. A further consequence of longstanding distention was that it was continually pressing against the diaphragm causing Shane to suffer reduced lung function. The additional distention from the colon filling with fluid as a result of the laxative treatment placed additional and unrecoverable strain upon Shane's respiratory effort. I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dose of laxatives. 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. - 1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018. 2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition .. 3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already 4. 2 distended abdomen with fluid 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 13 September 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 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 19 July 2023 ... ..ti...... ..... (l~~,./4/'~ ................... [SIGNED BY CORONER] 3
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.
gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Pencadlys Bwrdd Iechyd Prifysgol Bae Abertawe Un Porthfa Talbot, Parc Ynni, Baglan, Port Talbot, SA12 7BR Ffôn 01639 862000 Swansea Bay University Health Board Headquarters One Talbot Gateway, Baglan Energy Park, Port Talbot, SA12 7BR Phone 01639 862000 Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Dyddiad / Date: 27th September 2023 Mr Aled Gruffydd, Assistant Coroner – Swansea and Neath Port Talbot, The Guildhall, Swansea, SA1 4PE. Dear Mr Gruffydd, RE: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Further to your notification of a Regulation 28 Report following the inquest of Shane Luke West, Swansea Bay University Health Board is now able to provide a response on actions it intends to take to prevent future deaths. At the outset, I would like to thank His Majesty’s Coroner for the 2-week extension provided to the health board, to respond to the report. The extension allowed the health board to provide 6 weeks’ notice to clinical colleagues of a “Significant Case Review” meeting, enabling a multi-professional approach to the review of the case, the concerns highlighted within the report and to identify opportunities for prevention and improvement. The matters of concern highlighted within the report formed the agenda of the meeting. Please note the following outcomes and actions agreed: Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board 1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th August 2018. The death of Shane on 17th August 2018, was identified as an adverse incident by the health board and notified as a nationally reportable serious incident to Welsh Government . The health board acknowledged that in setting out the scope of its Serious Incident Investigation the administration of prescribed laxatives was not perceived to have been an issue at the time. Consequently, it was not included in the scope and was not highlighted as a problem during the investigation. It was therefore a missed opportunity to review the contradiction highlighted within the Regulation 28 Report. Action1.1: Amend the health board’s Serious Incident strategy meeting template to include an explicit question on whether medication (prescribed and/or administered) was a feature within the incident. The Health Board currently uses a template document to support the agenda of its Serious Incident Strategy Meetings. The aim is to provide a consistent checklist for setting the scope and lines of enquiry the serious incident investigation process and ensure that key aspects of healthcare provision and key stakeholders are identified. The template will be updated with an explicit question on the involvement of medications from 1st October 2023. Action 1.2: Swansea Bay University Health Board is currently implementing a Hospital Electronic Prescribing and Administration of Medicines (HEPMA) system. HEPMA is an electronic prescribing system that replaces paper-based prescribing is expected to improve the quality of prescribing and a reduction in drug administration errors. HEPMA is being implemented at Morriston Hospital as part of a structured programme, which is expected to be completed by March 2024. 2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane’s condition. All professionals attending the “Significant Case Review” meeting agreed that the development of a constructive, mutually beneficial relationship between the clinical team and patients with complex needs is key to keeping the patient safe and achieving positive clinical outcomes. It was acknowledged that the resources to achieve this goal are currently limited. At the time of writing, Morriston Hospital has only one dedicated Learning Disabilities Nurse, providing specialist input from Monday through to Friday. It is therefore important that those patients who are likely to benefit most from the service use this resource effectively and efficiently. gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 2 Action 2.1: Development and implementation of a Standard Operating Procedure (SOP) for the multi-disciplinary management of patients with complex needs following an emergency admission to acute hospital care. The intention is that when an agreed explicit length of stay trigger had been reached, a multi-disciplinary meeting would be called to consider all aspects of care delivery for a patient with complex needs. This approach would ensure a clear focus is maintained on the individual and ensure that specialist clinical knowledge is pulled together into a single clinical management plan, which is shared across multiple professions. A draft “standard operating procedure” will be developed for consideration by 31st December 2023. Action 2.2: Risk assessment to be undertaken on the provision of specialist Learning Disabilities nursing resource at Morriston Hospital to support compliance of Regulation 28 Report (issued July 2023) It is recognised that a single-handed learning disabilities resource is insufficient for the needs of Morriston Hospital. In addition, changes to emergency patient flow as part of the health board’s Acute Medical Service Redesign, will mean that all patients with complex needs requiring emergency admission will usually be admitted to Morriston Hospital. The assessment will need to consider actual service demand across the health board by the Learning Disabilities Service and an assessment of the gaps in service provision, thereby supporting the improvement work described in this response. A risk assessment will be presented to the health board’s risk scrutiny panel, by 30th November 2023 for consideration of inclusion on the health board’s risk register. Action 2.3: Review of current Learning Disabilities training programmes to ensure fitness for purpose and are accessible to staff. The current training that is offered to all staff in the health board is the Paul Ridd foundation training which has been developed by Swansea Bay University Health Board. The title of the course is “000 NHS Wales – Paul Ridd Learning Disability Awareness Training” and is accessible via the “Electronic Staff Record” system that is available to all employees. 3. Shane had an ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function. And 4. It was not clear whether medical professional appreciated this risk and whether the administration of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid. gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 3 It is anticipated that Action 2.1 (described above) will address, as part of an explicit clinical management plan, all clinical issues that emerge throughout the patient’s treatment. Should the plan need to be changed it would be through a multi-professional basis, accessing specialist clinical knowledge. Action 3.1: All staff that prescribe medications are to be reminded that the correct drug needs to be selected, dispensed, and administered in line with National Institute for Health & Care Excellence (NICE) and British National Formulary (BNF) Guidelines. Linked to Action 1.2, above. An adult ‘faecal impaction’ (8 sachets) of macrogol was prescribed in addition to the regular doses of the same. Increased staff awareness of the safe maximum dose of this drug (8 sachets per day) will be reinforced and increasing the level of scrutiny of dosage by the ward pharmacists. Action 3.2: All staff prescribing medications to be reminded of the importance of reporting adverse reactions to medication (Yellow Card System) Given that it has been concluded at the inquest that Shane’s death was linked to the use of the laxative, this event has been reported nationally via the “Yellow Card” scheme (Yellow Card report: GB-MHRA-MED-202309271100443290-ZMNCY). I am confident that the changes described above address your concern; however please do not hesitate to contact me if you require any further information. Yours sincerely, Interim CHIEF EXECUTIVE gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Page 4
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.