Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0291, written 15 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Aug 2023 |
|---|---|
| Reference | 2023-0291 |
| Deceased | Ian Darwin |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 (2) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. , Chief Executive Tees Esk and Wear Valleys NHS Foundation Trust West Park Hospital Edward Pease Way Darlington DL2 2TS And copied to Interested persons and to 3. CQC National Director of Patient Safety NHS England Wellington House, 133-135 Waterloo Road, London, SE1 8UG And : 1 CORONER I am Jeremy Chipperfield, senior coroner for the coroner area of County Durham and Darlington 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. https://www.legislation.gov.uk/ukpga/2009/25/schedule/5 https://www.legislation.gov.uk/uksi/2013/1629/contents/made 3 INVESTIGATION On 7th March 2023 I commenced an investigation into the death of Ian Darwin, 42. The investigation has not yet concluded and the inquest has not yet been heard. 4 CIRCUMSTANCES OF THE DEATH Death was caused by multiple injuries, Ian Darwin being found below , Durham. 1 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. – Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”) routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths. The above-mentioned inquest has not been heard; there has been no finding that the present death was attributable to acts or omissions in care. Although arising in the present investigation, the matter of concern is general and has arisen in the context of other investigations. Despite past assurances that the material circumstances have been addressed, the facts of the present case demonstrate that they continue to exist. I am aware that on 19th July 2023, Assistant Coroner Janine Richards notified you of the same concern arising from matters revealed by another investigation. TEWV identified Ian Darwin’s death as a “serious incident” (“SI”) for the purposes of The Serious Incident Framework1 (“the Framework”). The SI investigation (“SII”) process- defined in the Framework- was the means employed by TEWV to investigate this SI. The Framework defines SIs as “events where the potential for learning is so great, or the consequences to patients… so significant that they warrant particular attention to ensure these incidents… are investigated thoroughly… and trigger actions that will prevent them from happening again”. SIs “include acts or omissions in care that result in… avoidable death…”. Further, the “occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm”. SI investigations are the means “to ensure that weaknesses in a system are identified, to understand what went wrong … and what can be done to prevent similar incidents happening again”. Discussing one of the seven key principles of the SI Investigation- that they be Timely and Responsive- the Framework requires that SIs “must be reported without delay and no longer than 2 working days after the incident is identified”. One of “two key operational changes” introduced in the 2015 update was a single timeframe of 60 working days (from date of initial report) for completion of investigation reports. At an “early meeting” the investigator must “set out a realistic and achievable timescales and outcomes”. The present case: • Death occurred on 06.03.23; • I am informed that an investigator was initially appointed in around mid-June 2023; • By late June, TEWV were “unable to say” when the investigation would be complete; • The investigation is now expected to be complete in the week commencing 1 Serious Incident Framework, NHS England, first published in 2010 (last updated in 2015) 2 21.08.23 and its report to be finalised 18.09.23 The general situation: • TEWV SI death investigations, at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification; In some other cases delay is significantly longer than in the present; • • Such delays affect cases of all levels of seriousness. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you 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 11 October 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 Interested Persons. I have also sent it to NHS England and the CQC, who may find it useful or of interest. 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 15th August 2023 3
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.
11 October 2023 Mr Chipperfield HM Senior Coroner for County Durham and Darlington Office of the Chief Executive West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS PRIVATE AND CONFIDENTIAL Dear Mr Chipperfield, Re: Report to Prevent Further Deaths issued on 15 August 2023 in relation to Mr Ian Darwin I am writing to you in response to your direction in the prevention of future deaths notice served to Tees, Esk and Wear Valleys NHS FT on 15 August 2023 regarding the death of Mr Ian Darwin to provide in writing further information on what the Trust is doing to ensure Serious Incident reviews are completed within a timely manner as well as an update on the estimated time of arrival for each outstanding review. Just a short note at this stage to acknowledge receipt of your I am responding in the same format and with similar information to that in the response letter letter dated XXXX 2017 bringing sent last month, I hope this consistency will be helpful in enabling you and your team to see to my attention concerns raised the clear evidence of the progress we are making towards providing timely serious incident by your above named constituent reviews. I have continued to have direct oversight of how we are performing as I am in respect of XXXXXXX concerned that we improve our position as soon as possible. Our Board share this concern and therefore I have asked the Chief Nurse to keep our Quality Assurance Committee and our Board fully briefed. Whilst we are continuing to improve, we are paying particular attention to ensuring that families have good information to help them understand what a serious incident review is and how they can be involved. I have asked for an investigation to be carried out into the concerns raised by XXXXX following which I will send a detailed reply to you. We have good evidence that the recovery plan is meeting the improvement trajectory which we also report to our regulators and NHS England. With kind regards I hope the following summary is a helpful reminder of the action we have taken: Yours sincerely 1. We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed, this is a group of incidents that happened before February 2023. Some of these reviews are now being concluded and are going through the internal quality assurance checks before we share them with the families, submit to the ICS and to your office. The attached document gives the detail of this. 2. We have increased our internal capacity to review incidents by engaging our leaders in completing incident reviews in order that we can review incoming incidents and avoid further delays developing. We intend to continue to use some of this capacity and expertise in the future which is part of our plan to avoid delays in the future. Date 3. We have reviewed all incidents to ensure we have met Duty of Candour, that families have received notification of a review and have a named contact person and that we have a clear term of reference for each review. Colin Martin Chief Executive 4. We commissioned an external company who specialise in incident management to review our incident data and establish if incidents are being properly categorised and therefore responded to. We recognised that with a delay there was a risk we were missing issues and we wanted to be proactive. 5. We have adapted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be PSIRF, guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance. 6. We have also adapted our processes to ensure they identify immediate / early learning for each incident and that we take immediate improvement action where appropriate. We have examples of Trust wide patient safety briefings we have developed following immediate learning. 7. We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis. 8. We are reporting to our regulators and regional leaders via the mandated Quality Board our progress. 9. We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow. 10. To ensure timely presentation and review of reports we are introducing more flexibility to our Serious Incident Review Panels and as we have allocated a lot of reviews over a short period, we are planning ahead the capacity to ensure we can be efficient in our internal quality assurance in order that this does not delay the release of reviews to families once completed. 11. We will continue to expand our range of subject matter expert categories to lead specific types of reviews and we are currently contracting with an external provider who are a professional incident review company. Again, this is an opportunity to avoid delays in the future. We have previously shared a list of the serious incident reviews that we believe will be required by you and have indicated the dates that we expect the internal quality assurance process to be taking place. You can reasonably expect to receive most finalised serious incident reports within 2 weeks of the internal review however some will take longer than two weeks depending on, and this is difficult to predict, when the final report is available for review. From November 2023 we anticipate being able to allocate an SI review within the month the incident occurs. This is significant improvement. I hope this information meets your direction. Yours Sincerely Chief Executive
Tarncroft Lanchester Road Hospital Lanchester Road Durham DH1 5RD 11 September 2023 Private & Confidential Mr Chipperfield HM Senior Coroner for County Durham and Darlington Dear Mr Chipperfield Re: Report to Prevent Further Deaths issued on 15 August 2023 in relation to Mr Ian Darwin I am writing to you in response to your direction in the prevention of future deaths notice served to Tees, Esk and Wear Valleys NHS FT on 15 August 2023 regarding the death of Mr Ian Darwin to provide in writing further information on what the Trust is doing to ensure Serious Incident reviews are completed within a timely manner as well as an update on the estimated time of arrival for each outstanding review. I am responding in the same format and with similar information to that in the response letter sent last month, I hope this consistency will be helpful in enabling you and your team to see the clear evidence of the progress we are making towards providing timely serious incident reviews. I have continued to have direct oversight of how we are performing as I am concerned that we improve our position as soon as possible. Our CEO and our Board share this concern and therefore I am keeping our Quality Assurance Committee and our Board fully briefed. Whilst we are continuing to improve, we are paying particular attention to ensuring that families have good information to help them understand what a serious incident review is and how they can be involved. We have good evidence that the recovery plan is meeting the improvement trajectory which we also report to our regulators and NHS England. I hope the following summary is a helpful reminder of the action we have taken: 1) We have contracted in additional expert capacity in incident reviews to actively address the reviews that are delayed, this is a group of incidents that happened before February 2023. Some of these reviews are now being concluded and are going through the internal quality assurance checks before we share them with the families, submit to the ICS and to your office. The attached document gives the detail of this. 2) We have increased our internal capacity to review incidents by engaging our leaders in completing incident reviews in order that we can review incoming incidents and avoid further delays developing. We intend to continue to use some of this capacity and expertise in the future which is part of our plan to avoid delays in the future. 3) We have reviewed all incidents to ensure we have met Duty of Candour, that families have received notification of a review and have a named contact person and that we have a clear term of reference for each review. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 4) We commissioned an external company who specialise in incident management to review our incident data and establish if incidents are being properly categorised and therefore responded to. We recognised that with a delay there was a risk we were missing issues and we wanted to be proactive. 5) We have adapted processes to facilitate much earlier identification of the type of review required (concise or full) – this now takes place at the daily patient safety huddle, and we follow the national, soon to be PSIRF, guidance for this. It is anticipated that we will increase the number of concise reviews, where appropriate, in line with this national guidance. 6) We have also adapted our processes to ensure they identify immediate / early learning for each incident and that we take immediate improvement action where appropriate. We have examples of Trust wide patient safety briefings we have developed following immediate learning. 7) We have in place weekly sitrep / report out meetings to ensure we are sighted on the progress of each review and can provide any additional support to reviewers that may be needed. We will be monitoring our performance against the trajectory we have developed, and this is being reported to executive directors on a weekly and monthly basis. 8) We are reporting to our regulators and regional leaders via the mandated Quality Board our progress. 9) We have modified our documentation, reviewed our report templates and are utilising standard operating procedures to support efficient working and flow. 10) To ensure timely presentation and review of reports we are introducing more flexibility to our Serious Incident Review Panels and as we have allocated a lot of reviews over a short period we are planning ahead the capacity to ensure we can be efficient in our internal quality assurance in order that this does not delay the release of reviews to families once completed. 11) We will continue to expand our range of subject matter expert categories to lead specific types of reviews and we are currently contracting with an external provider who are a professional incident review company. Again, this is an opportunity to avoid delays in the future. I have taken the opportunity to share a list of the serious incident reviews that we believe will be required by you and I have indicated the dates that we expect the internal quality assurance process to be taking place. You can reasonably expect to receive most finalised serious incident reports within 2 weeks of the internal review however some will take longer than two weeks depending on, and this is difficult to predict, when the final report is available for review. From November 2023 we anticipate being able to allocate an SI review within the month the incident occurs. This is significant improvement. I hope this information meets your direction. Yours sincerely, Chief Nurse Enc. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
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