Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0276, written 24 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 | 24 Jul 2023 |
|---|---|
| Reference | 2023-0276 |
| Deceased | Alan Nippard |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal United Hospitals Bath NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M. E. Voisin
Her Majesty’s Senior Coroner
Area of Avon
Date: 24 July 2023
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Royal United Hospital
CORONER
1
I am Maria Eileen Voisin, Senior Coroner for the Area of Avon
CORONER’S LEGAL POWERS
2
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 7 July 2022 I commenced an investigation into the death of Alan
Christopher NIPPARD. The investigation concluded at the end of the inquest. The
conclusion of the inquest was a narrative including a finding of neglect.
Mr Nippard's death was caused by a pressure sore. The pressure sore was
preventable with the provision of basic nursing care, this was not provided. There
was a gross failure to provide basic nursing care. Once he had the pressure sore
his death could have been prevented with the provision of basic nursing care,
such as, skin care, regular re-positioning and personal care, this was not achieved
at all. He was not managed in line with recognised nursing practice and as a
consequence his death was contributed to by neglect.
3
The medical cause of death was recorded as:
1a Sepsis
1b Necrotising fasciitis/Fournier s gangrene
1c Pressure sore sacrum
II Septic arthritis, Type 2 diabetes mellitus, chronic kidney disease, left
ventricular systolic dysfunction
4 CIRCUMSTANCES OF THE DEATH
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
According to Mr Nippard’s GP, Mr Nippard had a medical history which included
poorly controlled type 2 diabetes, peripheral vascular disease, ischemic heart
disease and chronic kidney disease stage 4. He had also undergone amputations
of his toes due to non-healing diabetic ulcers.
His daughter, said in evidence that he was admitted to hospital on 30 th May 2022
following a fall at home. He said that he’d fallen forward and onto his knee. He
was lifted from the floor and onto his bed by his family where he remained until an
ambulance was called, when the decision was taken to admit him to the Royal
United Hosptial (the RUH) in Bath.
He was admitted via the Emergency department, then to the medical assessment
unit (MAU), and then onto the Orthopaedic ward – Pierce Ward on 1st June 2022 in
the early hours.
According to the Consultant Orthopaedic Surgeon, Mr Nippard was initially
admitted, with the diagnosis of right knee septic arthritis and an acute kidney injury
on top of his chronic kidney disease. Mr Nippard was on antibiotics and on 2nd June
2022 underwent a washout of his knee. On 8th June he had a second washout. By
17th June he was deteriorating, on 20th June his CRP was increasing. He said in his
evidence that the pressure sore was first documented by the orthopaedic team on
21st June, the surgeon described this now as - the bigger source of infection.
An MRI was requested but did not take place for 4 days; it was undertaken on 25 th
June and reported as showing no obvious sacral osteomyelitis it did show that it
had locally spread in the soft tissue.
By 28th June Mr Nippard was getting worse, his inflammatory markers were going
up and now his testicles were swollen, and there was a suspicion was that this
was Fournier’s Gangrene and there was a referral made to the Urology team.
The orthopaedic surgeon said that as far as the treatment for Mr Nippard’s knee
went, he felt they were winning that it was improving that if he hadn’t developed
the pressure sore his expectation was that he would have been discharged. He
agreed with the medical cause of death proposed.
A Consultant Urologist examined Mr Nippard on 28th June, he said that he had
evidence of a significant infection, that the only treatment was surgery, and all
agreed that surgery was not likely to help, and it would cause Mr Nippard
immense suffering in his last days. He explained that the other medical conditions
Mr Nippard suffered with caused him to be compromised, if he’d had a stronger
heart and kidneys then they would have operated
Sadly, after discussions with Urologists, Surgeons, Anesthetists and the Critical
care team it was decided that Mr Nippard was not fit for surgery, and he was
placed on priorities of care and died on 6th July 2022.
It was the view of the doctors who attended the inquest and gave evidence that
the pressure sore significantly contributed to Mr Nippard’s death.
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
CORONER’S CONCERNS
During the course of the inquest the 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.
opinion on what did happen, and what should have happened, in
I heard from the Trust’s Lead Tissue Viability Nurse,
and provided
relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure
sore was preventable, that it’s basic nursing care and this wasn’t achieved. That
once it had developed, if he’d had good skin care and the SSKIN bundle had been
followed the damage would have been minimized. When asked how bad the care
was
said - it was shocking.
had reviewed the notes
It was accepted that Mr Nippard did not have a sacral pressure sore when he was
admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was
on 2nd June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating -
for suspected deep tissue injuries to buttocks with blistering, stating the area
appeared overnight.
5
I was told that there were a number of areas of concern with regard to the risk
assessment, management and care and treatment that Mr Nippard received
including:
• That the screening tool completed on 31st May scored Mr Nippard as, not at
risk of a pressure sore – this was wrong; he was at risk due to his
immobility and diabetes which increased the risk of a pressure sore
developing, in addition to his age and his medical history. He should have
been scored high risk. Because of this - nothing happened and it should
have. Mr Nippard should have been on an air mattress and he should have
been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it
•
should have been.
It is recorded that he was on an air mattress on Pierce ward on 1st June but
the time of this is unknown. This meant he probably went up to 2 days after
his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post
admission, (1st June) it did record his risk as high, this is a significant
delay.
• Once recorded as high risk Mr Nippard should have been reassessed every
week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely
completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were
carried out were ad hoc and inaccurate, sometimes skin was recorded as
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns –
sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact that Mr Nippard spent long periods of time
on his back with little or no evidence of offloading of the sacrum or heels at
all. He should have been repositioned every 2-3 hours during the day and
between 2-4 hours at night. There was no structured re-positioning at all.
It was estimated that every day he was in hospital he was on his back for
22 ½ hours and there was no sustained time off his sacrum and there
should have been.
•
• When he was sat in his chair there is no evidence that he had an air
cushion to sit on and when sat, he should have been stood hourly.
It was raised that there was a query of his own compliance but there is only
2 occasions on 6th and 20th June when he declined to be moved
•
• There was no evidence of the use of 2 sliding sheets to assist with moving
him.
• On 11th June it was a podiatrist who raised the new pressure sore on the
right heel and completed an incident report – this should have been
managed and picked up by the nurses in their daily checks. In addition he
should have had repose boots to prevent this and there is no evidence they
were used at all.
• Mr Nippard had a catheter and incontinence – he should have been
checked regularly, offered the toilet, the commode, bed pans should have
been a last resort. She could not see this was achieved at all. The fact Mr
Nippard was left to soil the bed was not acceptable care and that the limited
personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a
fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr
Nippard’s admission, however, I have not been reassured by those involved with
Pierce Ward that this will not happen again. Specifically, I have been advised by
The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The
Interim Deputy Divisional Director of Nursing for Surgery and The Divisional
Director of Surgery have confirmed that there have been two pressure sore
incidents on Pierce Ward this month (July 2023). I have been told that the reason
for this could be the need for training of staff on Pierce Ward on : risk assessment,
prevention care and treatment of pressure sores by the tissue viability team.
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.
YOUR RESPONSE
7
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 21st September 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken,
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
setting out the timetable for action. Otherwise you must explain why no action is
proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons - family of the deceased.
I am also under a duty to send the Chief Coroner a copy of your response.
8
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.
24 July 2023
9
Signature
Maria Voisin Senior Coroner for Avon
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
19th September 2023 Sent via Email Only HM Senior Coroner for Avon Dear Madam Directors’ Office Royal United Hospitals Bath NHS Foundation Trust Combe Park Bath BA1 3NG Response to Regulation 28 Report Regarding Mr Alan Nippard On the 24th July 2023 a Regulation 28 Report was received, raising the following concern: I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on: risk assessment, prevention care and treatment of pressure sores by the tissue viability team. Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training. The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SSKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected. A number of other actions have been implemented which include: increasing staffing levels 24 hours per day, the introduction of bedside patient care handovers, the monitoring of comfort- rounds, Senior Sister and Matron ward rounds, checking on patient safety, patient experience, patient care and nursing documentation. A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and action actions are in place to achieve 95%. I have met with Mr Nippard’s family a number of times and I have shared with them my sincere apologies for the failings in his care. We are committed to ensuring our care does not fall below the standards we expect and these actions will continue to prevent similar lapses of care occurring in the future. Yours faithfully Chief Executive
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