Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0400, written 20 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 | 20 Oct 2023 |
|---|---|
| Reference | 2023-0400 |
| Deceased | Valerie Simmons |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| 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.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 1 CORONER , Community Nurse Locality Team Lead I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 20/10/2023, I concluded an inquest into the death of Valerie Ann Simmons who died on 11/01/2023. . The medical cause of death was recorded as: 1a) Hypovolaemic Shock 1b) Left Thigh Haematoma 1c Low Molecular Weight Heparin and Warfarin Therapy with high INR for Metallic Mitral Valve Replacement. II Ischaemic Heart Disease, Congestive Cardiac Failure, Frailty I recorded a Narrative Conclusion that Mrs Simmons died from a known complication (bleeding) of a necessary medical procedure (anti- coagulation.) 4 CIRCUMSTANCES OF THE DEATH Mrs Simmons was well known to the community nursing team. She had a past medical history that included a mitral valve replacement in 2007 following which she was prescribed warfarin with a target therapeutic INR of 3.5. In December 2022, it was noted her INR levels were sub- therapeutic and so she was prescribed bridging Fragmin therapy. Her NEWS score was recorded as 5. Community nurses attended daily. On 7/1/23, she had an injection of Fragmin into her left thigh. On 8/1/23, she was found to have developed a large haematoma. In spite of her changed presentation, there were no recorded observations that objectively demonstrated she was otherwise ‘well.’ Her INR was tested on 9/1/23 and found to be 4.9. A doctor attended and advised admission into hospital which Mrs Simmons initially declined. 1 Information Classification: CONTROLLED She subsequently changed her mind but an email to advise the doctor did not reach him. An ambulance was later called, and Mrs Simmons was admitted into Royal Cornwall Hospital. She deteriorated and died in the hospital on 11/1/23. 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 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. – It was accepted in evidence that: - Where there was a change in a patient’s presentation, it would be expected that a set of observations would be undertaken and recorded in a patient’s notes; - Further training related to the risks of hypovolaemia in an anti- coagulated patient would be beneficial. 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 16/12/2023. 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 2 Information Classification: CONTROLLED the release or the publication of your response by the Chief Coroner. 9 [DATE] [SIGNED BY CORONER] 20/10/2023 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.
Mr Andrew J. Cox H.M. Senior Coroner Cornwall & the Isles of Scilly Coroner’s Area Director of Nursing and AHPs Carew House Beacon Technology Park Dunmere Road Bodmin PL31 2QN louise.dickinson2@nhs.net Date: 30 November 2023 Dear Mr Cox Regulation 28 report to prevent future deaths following the inquest into the death of Mrs Valerie Simmons I am writing in response to the Regulation 28 report, in my role as Director of Nursing and Allied Health Professionals on behalf of Cornwall Partnership NHS Foundation Trust. I wish to begin by offering my sincere condolences to Mrs Simmons’ family. I am deeply sorry for their loss. In this letter I will outline the action we will take to address the concerns raised at Mrs Simmons’ inquest and to provide assurance that our learning has been identified and actioned. I will set out the context of the community nursing roles and responsibilities with patients receiving anticoagulant medication, explaining the polices and training currently in place. Three meetings have been held during November 2023, with community nursing clinical, operational, and patient safety leads to understand the specific issues in this case to ensure the right response to the concerns you have raised: Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN Margaret Schwarz, Chair. Debbie Richards, Chief Executive. Call us on 01208 834 600 | Visit our website at cornwallft.nhs.uk 1. The use of observations when there is a change in a patient’s presentation. 2. Training related to the risks of hypovolaemia in an anti-coagulated patient. The community nursing service aims to deliver high quality nursing services spanning care pathways between primary and secondary care. This service provides a pivotal role ensuring the co-ordination and seamless provision of care to people in their place of residence, with the aim of promoting personalised and anticipatory care to promote independent living. The Cornwall Partnership NHS Foundation Trust, (CFT) integrated community standard operating procedure (SOP), which includes community nursing, states that an integrated team core assessment is the agreed initial assessment which must be completed on a community nurses’ first visit to a patient. Additional assessments will be completed as clinically indicated. The expectation is that basic observations are taken on initial assessment as a baseline so that if the patient’s clinical presentation changes, they are repeated and compared. In this case, Mrs Simmons was receiving regular visits by community nurses to administer anticoagulant injections and international normalised ratio (INR) point of care testing. Anticoagulants are used to reduce the risk of thrombo-embolic complications in patients at increased risk. People prescribed anticoagulant medication will routinely have a laboratory blood test performed to ensure their INR is within therapeutic limits. This ratio is a representation of the pro-thrombin time and is measurement of how long it takes the blood to clot. A high ratio INR may indicate an increased risk of bleeding, a low ratio may indicate a risk of blood clot development. Community nurses use a portable INR monitoring device for point of care testing, (POCT) providing an instant measurement of INR to reflect the anticoagulant. POCT is an established part of community nursing clinical practice and offers rapid provision of tests for people in their own homes. A CFT SOP has been developed to ensure that consistent procedures are in place throughout Cornwall. The SOP applies to both registered (e.g., nurses) and unregistered (e.g., health care assistants) community nursing staff members responsible for INR point of care testing. The procedure described in this standard should only be carried out by, registered and unregistered, Page 2 members of the community nursing team who have been specifically trained and assessed as competent in the use of the INR POCT device, and who can demonstrate an understanding of the role of INR testing including a basic interpretation of the INR result. Practitioners must demonstrate competence and be signed off before performing this role. However, on review of the SOP and training video, conducted in response to the Regulation 28 report, we have identified that it does not include awareness on the tendency of patients taking anticoagulants to have bleeding complications such as haematomas, or how to manage the side effects/consequences for example hypovolaemia. (A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise. Sometimes, haematomas may not show up as a bruise and can be deeply located. Haematomas are usually caused by an injury to blood vessel walls [such as veins or arteries] which allow the blood to escape and collect together to form a lump). The groups first recommendation for action to take in response to the Regulation 28 report is for an update of the INR POCT SOP and training video to include awareness of symptoms and prompt for basic observations in any change of clinical presentation such as a haematoma. The recommendation of the group is that POCT training is essential and mandatory for community nursing staff undertaking POCT as a clinical skill. On review of training for community nursing, we have identified that the community assessment of sick patient training, (CASP) is a mandatory training requirement for the acute care at home and home first teams only. As a result of learning from this incident, the group has recommended that CASP would be an advantageous course to be added to the registered community nurse’s mandatory training, particularly as the acuity of patients in the community is increasing. The CASP training will update mandatory skills for registered community nurses to cover: • Recognition of the deteriorating patient. Page 3 • NEWS2 assessment (National Early Warning Score which is a tool to improve the detection and response to clinical deterioration in adult patients). • Communication including the importance of documentation. • Sepsis • Anaphylaxis • Acute kidney injury • Diabetes (including Hypoglycaemia) • Breathing issues • Clinical observations and physical health assessment The training will support community nurses to use clinical observations when there is a change in patients’ clinical presentation. This recommendation will lead to 260 staff needing additional CASP training which will require 3-4 further courses to be delivered per year. The decision has been made to follow this recommendation. We recognise that policy updates and training changes can take time. To reassure the family, as part of our meetings, we have undertaken learning from experience to develop a poster which will be shared across all community nursing teams demonstrating the importance of recognising the signs of a deteriorating patient and highlighting the importance of taking and recording basic observations when there is change in clinical presentation. Thank you for highlighting your concerns. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Page 4 Yours sincerely Director of Nursing and AHPs Enc Page 5 Recommendations Action to be Taken Lead Responsibility Date to be completed Expected outcome 1. Ensure the point of care testing SOP and training includes guidance on side effects for people taking anticoagulant medication specifically increased tendency of bleeding complications such as bruising or haematoma. Prompting basic observations if any change in clinical presentation. Amend the current SOP and edit the training video for point of care testing INR’s to add further guidance on side effects for people taking anticoagulation medication including increased tendency of bleeding complications such as bruising or haematoma prompting basic observations if any change in clinical presentation. 28 Feb 2024 Community Nursing Practice Educator SOP will be updated and available for all staff to access and information on the updated SOP shared widely with the community nursing teams. Training video will be updated to include guidance on the side effects of taking anticoagulants. 2. Strengthen the requirement for staff who undertake POCT in the community. POCT training to become mandatory for staff undertaking POCT clinical skill. All relevant staff to undertake the training. 28 Feb 2024 Community Nursing Practice Educator. POCT add to the mandatory training matrix for community nurses and evidence of training compliance. Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN Margaret Schwarz, Chair. Debbie Richards, Chief Executive. Call us on 01208 834 600 | Visit our website at cornwallft.nhs.uk 3. Registered community nurses to undertake the CASP course. Seek investment for future capacity to training team for additional CASP training sessions, (3-4 per year) and deliver the additional sessions. Head of Education & Training 30 Jan 2025 All registered community nurses will have completed the CASP training by January 2025 evidenced by training records. 4. Learning from experience poster to be shared across community nursing teams highlighting the importance of taking basic observations when there is any change in clinical presentation of the patient and importance of documentation. Development of learning from experience poster and sharing of this at Clinical Quality Assurance Meetings to all Community nursing Teams. Central Business Governance Partner 31 Dec 2023. Evidence of poster. Minutes of the CQAG meetings. Signed sheet from each community nursing team to indicate all staff have read this. Page 7
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