Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0324, written 8 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Sep 2023 |
|---|---|
| Reference | 2023-0324 |
| Deceased | Cherry Garland |
| Coroner | Robert Sowersby |
| Coroner area | Avon |
| 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.
M. E. Voisin
Her Majesty’s Senior Coroner
Area of Avon
8 September 2023
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive, University Hospitals Bristol and Weston NHS Foundation
Trust (‘UHBW’)
1
CORONER
I am Robert Sowersby, Assistant Coroner for the Area of Avon
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 31 October 2022 an investigation commenced into the death of Ms Cherry Lynne
GARLAND, aged 77. The investigation concluded, at the end of a 2-day inquest, on 17
August 2023.
The medical cause of death was:
1a)
1b)
2)
Sepsis and Right sided heart failure
Coronary artery atheroma (operated)
Chronic Lymphocytic leukaemia
The narrative conclusion of the inquest was as follows:
Cherry Garland was 74 years old and had a background of known heart problems and
Chronic Lymphocytic Leukaemia when she underwent a percutaneous procedure to
examine and stent her coronary arteries. Unfortunately one of her arteries perforated
during the procedure and she required emergency open-heart surgery. The surgery
was successful, but she suffered vascular injury from the presence of an arterial sheath,
and went on to develop Covid. She then developed pneumonia, which in turn triggered
sepsis, and sadly she died on 11 October 2022, in the Bristol Royal Infirmary, as result
of both sepsis and right-sided heart failure.
4
CIRCUMSTANCES OF THE DEATH
It is not necessary to give more detail about the circumstances of death in this case,
because the issue I am addressing in this report did not contribute to Ms GARLAND’s
death – it was ‘incidental’ to her death, but still extremely important.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern as
follows –
Background
•
I heard evidence that when Ms GARLAND was on the Cardiac High
Dependency Unit ‘HDU’ (part of the Intensive Care Unit) she was receiving
intravenous antibiotics
• When she then transferred from HDU to the Cardiac Ward there was a
transcription error, and these antibiotics were accidentally omitted from the list of
medications that she should be given on the new ward
• As a result Ms GARLAND’s antibiotics were discontinued accidentally
•
I heard (and accepted) evidence that it would have been reasonable to
discontinue antibiotics in any event at the time of Ms GARLAND’s transfer
• Notwithstanding that fact, I remain deeply concerned by the circumstances in
which the error took place
My concerns
•
I heard evidence from an ICU Consultant (who I found to be both a reliable and
an impressive witness), who told me, among other things, that:
-
“… Transcription errors have always been a problem…” the ideal way to get
rid of them would be to have a system [in the rest of the hospital] that speaks
to ours
- The ICU retains lists of its patients’ medication on a computerised/electronic
system
- The rest of the wards in the hospital do not operate the same system
- The available systems do not speak to each other (to put it in somewhat
colloquial terms)
- Efforts to address that problem have proved fruitless
- As a result, every time an inpatient moves from ICU to another department in
the hospital, an appropriately qualified member of staff has to physically
transcribe that patient’s medication list
- With (for instance) 10 patients moving per day, 15-20 medications per
patient, and multiple elements for each medication (name; dose; timing;
indication; start date; signature etc.), “at a conservative estimate 1,500 to
2,000 elements [are transcribed] daily”
(Coroner’s comment: for obvious reasons this creates enormous potential for
human error)
- There are a limited number of people who can prescribe (and are therefore
able to perform this task); in critical care they are the same people who are
responsible for providing care
-
-
“We really need a second check… funding for more pharmacists… as a
Trust we’ve fallen short of ICU national standards for years in terms of the
number of pharmacists per bed and medicines reconciliation”
“I spoke to the Chief Pharmaceutical Officer – he has submitted 5 proposals
in the last 7 years to try to get the deficit funded… [without success]”
In summary, my view is that the circumstances currently in place create a very real (and
known) risk that transcription errors will continue to occur. This in turn endangers
patients, and creates a risk that people will die in the future as a result of such errors.
It is, sadly, very easy to envisage circumstances in which a patient might not receive
essential medication at all, might receive the wrong dose of the medication they need,
or might receive the wrong medication altogether, because of a transcription error.
In my opinion there is a risk that future deaths will occur unless action is taken, and in
the circumstances it is my statutory duty to report to you.
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3 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 family of the deceased.
I have also sent it to the Care Quality Commission 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
08/09/2022
Signature
Robert Sowersby Assistant Coroner Area of Avon
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.
Trust Headquarters
Marlborough Street
Bristol BS1 3NU
Email:
website: www.uhbw.nhs.uk
3 November 2023
Mr Robert Sowersby
Assistant Coroner Area of Avon
The Coroner’s Court
Old Weston Road
Flax Bourton
BS48 1UL
Dear Mr Sowersby,
I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 8 September
2023. Thank you for providing the Trust with the opportunity to further consider the concerns you
have raised. We recognise the importance of continuously reflecting upon our current practice in
order to identify action we can take to improve patient safety.
To that end, I have requested the assistance of the Divisions involved in the deceased’s care, and
the Chief Medical Officer, to address your concerns, as set out further below.
HM Coroner’s concerns:
1. The ITU system where medicines are prescribed does not talk to an electronic
medicines system in the rest of the hospital.
I understand that your concern has arisen from evidence given by an ICU Consultant at the
inquest. It may be helpful to explain the local and national context of the systems, in order to
provide assurance to you in relation to this issue.
In UHBW the ITU electronic record system (Phillips ICCA) is a specialist critical care system that
provides full electronic records of the complexity of care delivered to patients in intensive care,
including a complex prescribing function.
For patients in the ward areas of our hospitals, medicines are currently prescribed using paper
drug charts. A Trust-wide system for electronic prescribing and medicines administration, Careflow
Medicines Management (CMM), for ward based patients is currently being implemented across
UHBW where it will be used across most of our clinical areas. This excludes intensive care units,
theatres and the central delivery suite at St Michael’s Hospital because CMM does not have the
functionality to safely manage variable infusions typically used in these areas. The CMM system
will introduce a range of additional risk controls to prevent prescribing and administration errors
such as a second check for controlled drugs, allergy checking, interaction checking and therapeutic
duplication warnings. The timeline for this is subject to confirmation with external suppliers.
In addressing transcription challenges within the different clinical areas of UHBW, it may seem
desirable to have a unified prescribing system. However, it’s important to acknowledge that the
Electronic Patient Record system used for ward-based patients would not be suitable for use on
ITU given the specialised requirements of the Intensive Care system. This challenge is not unique
to UHBW; across the NHS, different clinical areas, including ITU, maternity, and pathology, often
operate with disparate systems due to their complex, individual requirements.
We have also considered the possibility of integration and data-sharing between the specialised
ITU system (Phillips ICCA) and the Electronic Patient Record system used for ward-based
patients. Unfortunately, this pursuit is significantly complicated by intricate and multifaceted
obstacles. For example, one notable challenge is the harmonisation of drug formularies across
systems to enable the transfer of information. ITU prescribing demands a level of complexity far
exceeding that of ward-level prescribing. Maintaining this heightened complexity within the
Electronic Patient Record at ITU standards would require extensive, ongoing effort and would
inadvertently introduce unnecessary risks into ward-level prescribing practices.
In addition, achieving interoperability between the two systems would require extensive technical
input from and between the two external competing commercial providers, which would be outside
of the Trust’s control.
We recognise that management of medical records and prescriptions across the Trust is a complex
issue, particularly where different systems are in use across different specialities. Unfortunately,
for the reasons set out above, it is not possible to introduce a unified electronic prescribing system
at this time.
2. The physical transcription of each patient’s medication list on step down from ITU
and the limited number of people who can perform this task.
Medicines reconciliation, as defined by the Institute for Healthcare Improvement, is the process of
identifying an accurate list of a person's current medicines and comparing them with the current list
in use, recognising any discrepancies, and documenting any changes, thereby resulting in a
complete list of medicines, accurately communicated. At transfers of care, such as stepdown from
ITU to the ward, this includes clinical decision making about starting, restarting, stopping, or
changing prescriptions for medicines. Even with a unified prescribing system extending from critical
care to ward based settings, it would still be crucial that a qualified individual carefully reviews and
approves medication adjustments.
As there will always be a need for a human element in a system for transcribing medicines
between care settings, mitigation at UHBW is focussed on reducing risk as far as is possible, for
example, by providing optimum possible conditions for this task and staff with the appropriate
expertise.
Actions already in place to reduce the risk of transcription errors between ITU and the wards:
• Prescribers completing the ward drug chart obtain a second check from a doctor.
• Routine training for junior and rotational ward pharmacists receiving ICU step down
patients.
• Designated quiet transcriptions space.
• Routine application of standard analgesic regimen labels for surgical patients.
• Training for prescribing delivered by a pharmacist at the new doctor induction for each
rotation.
• Participated in a regional audit to share learning from other Trusts and identify potential
new opportunities for reducing risk of medication errors at step down.
Additional actions UHBW are taking to reduce the risk of transcription errors:
•
•
Introduction of CMM will reduce the risk of transcription between wards at UHBW and other
medication errors by providing a standardised formulary with standard regimen templates
and electronic calculations that will promote best prescribing practice; whereas transcribing
to paper is open ended with no prescriber feedback.
Introduction of CMM will improve efficiency of medicines reconciliation by providing the
ability for remote checking and medicines reconciliation.
• You heard in evidence that proposals for additional resource in Pharmacy were presented
but, regrettably, there were competing proposals from higher risk areas, which the Trust
had to prioritise. I asked the Chief Medical Officer to oversee a review of the funding
requests, and entries on the Trust’s risk register, to provide further assurance around this. I
confirm that the Trust will invest in additional pharmacy staff for adult ITU to ensure all
medicines reconciliation at step down is completed by a suitably trained individual. This will
provide a pharmacy medicines reconciliation five days a week. In addition, this investment
will provide a safety net review of weekend medicines reconciliation previously undertaken
by doctors and advanced nurse practitioners at the weekend at the time of transfer out of
ITU.
Kind regards,
Chief Executive
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