Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0373, written 5 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2023 |
|---|---|
| Reference | 2023-0373 |
| Deceased | Iris Fordham |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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.
MRG IRVINE
SENIOR CORONER
EAST LONDON
East London Coroner's Court, Queens Road Walthamstow, E17 SQP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Trust
, Chief Executive Officer, Barts Health NHS Foundation
2. Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care
1
CORONER
I am Graeme Irvine, senior coroner, for the coroner area of East London
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.
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3
INVESTIGATION and INQUEST
On 2nd January 2023 this Court commenced an investigation into the death of Iris Elaine
Fordham aged 95 years. The investigation concluded at the end of the inquest on 5th
October 2023. The court returned a narrative conclusion;
Iris Elaine Fordham died in a step-down care centre on 1st January 2023, she was
recovering from a surgical repair of injuries sustained in a fall. Her death was caused by
worsening symptoms of Alzheimer's disease.
Mrs Fordham's medical cause of death was determined as·
1.a. Alzheimer's disease
2. COVID-19, fractured neck of femur, suspected colorectal cancer
4
CIRCUMSTANCES OF THE DEATH
Iris Fordham was admitted to hospital on 22nd November 2022 having sustained an
unwitnessed fall in the community, her admission was not to treat any traumatic injury,
but rather that concerns existed about her ability to ensure her own safety due to
Alzheimer's disease.
Mrs Fordham was placed on 1:1 nursing care in order to, amongst other things, mitigate
the risk of further falls .
Those caring for Mrs Fordham failed to conduct a falls risk assessment, introduce a falls
care plan, or conduct an enhanced care assessment when indicated , these successive
failings resulted in removal of 1: 1 care and then an unwitnessed fall on 25th November
2022. Mrs Fordham sustained a broken neck of femur and underwent a surgical repair.
Post surgically, she was transferred to a step-down care centre where she died on 1st
January 2023.
5
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 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. -
1. The poor quality of recording clinical records impeded the Trust's governance
processes, in that the author of a serious incident investigation was unable to
rely on clear evidence to understand why essential actions were not carried out
in Ms Fordham's care.
2 . The Trust failed to complete a falls risk assessment of Ms Fordham.
3. The consequence of (2) was that no falls care plan was completed.
4 . The fact that the failures at (2) & (3) were not detected and remediated by
successive clinical staff members suggests that they did not read essential parts
of the clinical record when providing care. The cumulative failings, on the part of
multiple healthcare professionals suggests a culture of indifference inimical to
the provision of safe and effective practice.
5. The Trust has not considered any step to resolve individual failings in care
through disciplinary or regulatory channels.
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 8th December 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons the family of Mrs Fordham I have also sent it to the local Director of Public
Health who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it
useful or of interest.
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 w o he believes may find it useful
or of interest.
You may make representations to me, the coroner, at th
the release or the publication of your response.
time of your response, about
9
[DATE] 05/10/2023
(SIGNED BY CORONER] ct '{I
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.
From Helen Whately Minister of State for Social Care 39 Victoria Street London SW1H 0EU Mr Graeme Irvine Senior Coroner for the coroner area of East London East London Coroner’s Court Queens Road, Walthamstow London E17 8QP 18 June 2024 Dear Mr Irvine, Thank you for your Regulation 28 report to prevent future deaths dated 5 October 2023 about the death of Ms. Iris Elaine Fordham. I am replying as Minister with responsibility for dementia. Firstly, I would like to say how saddened I was to read of the circumstances of Ms. Fordham’s death and I offer my sincere condolences to their family and loved ones. Please accept my sincere apologies for the significant delay in responding to this matter. The report raises concerns that the hospital that admitted Ms Fordham failed to follow standard practices for a patient with dementia and at risk of falls. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. The Barts Health NHS Foundation Trust have confirmed that a Falls Risk Assessment was completed for Ms. Fordham but that this was missed by the investigator conducting the Serious Incident Review. However, an Enhanced Care Assessment and Care Plan, required for a patients with dementia and at risk of falls, was not completed for Ms. Fordham. The Trust have agreed to implement the following actions to ensure robust implementation of standard practices for patients with dementia and/or at risk of falls and to improve incident investigation and divisional governance: a) all patients at risk of falls should have an up-to-date Enhanced Care Assessment which should be discussed at the multi-disciplinary meetings and of which the nurse in charge should be aware; b) the risk of fall ID band should be used for any patients with a history of falls or deemed to be at risk of a new fall; 1 c) all permanent members of staff to complete the 4 Harms and Slips, Trips and Falls Statutory and Mandatory Training; d) a Falls Risk Assessment and Care Plan and an Enhanced Care Assessment should be completed on all patients admitted with confusion or dementia, and those over the age of 65 within 6 hours of admission to ward or clinical area; e) education regarding the Falls Policy and Action Plan are currently being revisited with staff in ringfenced team time; f) a training plan for Falls Risk Assessment on the Computerised Records System (CRS) is to be rolled out and will be audited once the training plan has been completed; g) the information shared at multidisciplinary team meetings should include details of how and why the patient presented as well as the outcomes of Falls Risk Assessment and Enhanced Care Assessment to ensure that appropriate decisions about care are made; h) staff involved in Ms. Fordham’s care should be given feedback, so that they can i) j) reflect and improve the care that they provide their patients; the Trust will explore having the full Falls Risk Assessment mandated on the Computerised Record System; and findings and learnings from the review will be shared in Trust Mortalist and Morbidity meetings. Further, the Trust is conducting a diagnostic assessment on essentials of care and associated patient risk assessments (including falls). The Care Quality Commission continues to have regular engagement with the Trust as part of their usual mornitoring powers. This includes continued monitoring of the agreed actions the Trust provided the CQC with regarding improving their serious incident investigation and divisional governances. You may wish to refer to the Trust for an update on the status of the above listed actions. In the community, as per the Care Act 2014 (legislation.gov.uk), where it appears that an adult may have needs for care and support, the local authority is required to carry out a needs assessment. To support local authorities in improving the care provision for patients discharged from hospital, £600m has been made available through the Discharge Fund for 2023/24. Further guidance on support and services available following a dementia diagnosis can be found on NHS.uk. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, HELEN WHATELY
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