Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0425, written 1 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Nov 2023 |
|---|---|
| Reference | 2023-0425 |
| Deceased | Sasha Mishabi |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: St Andrew's Healthcare, Birmingham
CORONER
I am Emma Brown, HM Area Coroner for Birmingham and Solihull
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.
INVESTIGATION and INQUEST
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On 2 May 2023 I commenced an investigation into the death of Sasha Honey MISHABI. The investigation
concluded at the end of the inquest . The conclusion of the inquest was; Natural causes.
CIRCUMSTANCES OF THE DEATH
Mr Mishabi died at the Queen Elizabeth Hospital Birmingham on the 18th April 2023. He was a detained
mental health patient under section 37/41 of the Mental Health Act at Lifford Ward, St Andrew's Healthcare
('SAH'), Birmingham for the treatment of personality disorders and schizoaffective disorder of a severe and
enduring nature. Mr. Mishabi's physical health was also poor due to diabetes mellitus type 2, essential
hypertension, end stage renal failure and heart failure, he also had poor nutrition and generally used a
wheelchair. Mr. Mishabi's personal hygiene was poor and due to his mental health condition he would
often refuse assistance despite suffering episodes of incontinence. He had developed painful skin ulcers
to his buttocks that were first identified at SAH on the 15th March 2023 and initially thought to be pressure
sores. Dressings were applied.
Mr. Mishabi was admitted to the Queen Elizabeth Hospital on the 17th March 2023 for management of
urinary retention. He was found to have a urinary tract infection and anaemia. He was treated and
clinically stable when discharged back to SAH on the 2nd April 2023. On admission it was also identified
that he had grade 2 ulcers to his left buttock that were thought to be pressure related and was managed
accordingly.
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Following discharge the ulcers proved difficult to manage and deteriorated. Therefore Mr. Mishabi was
admitted to the Queen Elizabeth Hospital on the 6th April 2023 for input from the tissue viability team at
which time signs of local infection were identified which were treated with antibiotics. He was reviewed by
a tissue viability specialist on the 12th April 2023 who felt that the ulcers were not pressure ulcers.
Consequently on the 14th April he underwent a surgical review, a pelvis CT with contrast and a
dermatology opinion was obtained to consider what the nature of the ulcers was and how they should be
managed. No abcesses or collections were identified and the appropriate management was advised to be
ongoing antibiotics. Mr. Mishabi continued to be clinically stable with all observations within normal limites
until the 16th April 2023 when he had an episode of pyrexia and tachycardia during the morning prompting
investigations. The only other cause for concern on the 16th was a low blood sugar during the early
evening but this responded to treatment. However at 22:35 on the 16th April 2023 Mr. Mishabi suddenly
became unrousable and suffered a cardiac arrest. He was successfully resuscitated but subsequently
developed an overwhelming bronchopneumonia which despite treatment lead to his death.
Based on evidence heard at the inquest from a variety of clinicians and
medical cause of death was determined to be:
, pathologist, the
1a Bronchopneumonia
1b Cardiac Arrest
1c Local infection of unknown origin with diabetes mellitus; hypertension; end stage kidney
failure; ischaemic heart disease and heart failure
II Skin infection of the buttocks with superficial ulceration
The skin ulcers were determined not to be pressure related and at post mortem were seen to be healing
and uninfected, therefore it was concluded that they did not play a significant part in Mr. Mishabi's death.
However, the inquest did examine the pressure area risk assessments, prevention management and ulcer
care at the University Hospitals of Birmingham and St. Andrew's Healthcare.
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. –
1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and
Management '
Policy Due
to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure
damage and ought to have had weekly waterlow assessments and daily skin inspections with more
frequent assessment and inspection to be considered in the event of change such as the
development of an ulcer. Statements were provided from
, Consultant Psychiatrist, and
, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The
statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and
provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and
Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that
had forgotten that there was such a policy (he initially denied there was a
policy/procedure for waterlow assessments and later, after the policy had been produced, said
there was but he had forgotten about it). The areas of non compliance identified at inquest were as
follows:
a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and
5
4.3 of the policy;
b. failure to carry out and/or adequately record daily skin inspections in accordance with
paragraph 4.4 of the policy;
c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what
were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph
4.3 of the policy;
d. failure to consider increasing the frequency of skin inspections and carry out and/or
adequately record any skin inspections between the identification of ulcers on the 15th
March 2023 and the admission to hospital on the 17th March 2023 in accordance with
paragraph 4.4 of the policy; and
e. failure to make a datix incident report when grade II lesions were identified on the 15th
March 2023 in accordance with paragraph 4.7 of the policy; and
f. failure to provide adequate monitoring and oversight of the implementation of the policy in
Mr. Mishabi's case in accordance with paragraph 5 of the policy. .
2. SAH Governance, Quality Assurance and Serious Incident processors
a. SAH had not identified the issues with compliance with the policy before the inquest and
could offer no explanation for how/why the failures occurred and persisted.
b. No serious incident investigation had been carried out by SAH into Mr. Mishabi's death
because it was mistakenly believed that the ulcers developed during the admission to
hospital between the 17th March and 2nd April 2023. However, it was acknowledged in a
statement from
ulcers were present from the 15th March 2023.
of the 14th September 2023 that there were records showing
c.
SAH Deputy Medical Director, gave evidence that the failures to comply with the
policy ought to have been identified by review of the physical health dashboard in monthly
ward governance huddles and the monthly divisional Integrated Quality and Performance
meeting (IQPR). As there had been no investigation into what went wrong she could not
explain why these systems did not work.
ACTION SHOULD BE TAKEN
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In my opinion action should be taken to prevent future deaths and I believe you have the power to take
such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 27
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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
and University Hospitals of Birmingham.
I have also sent it to Birmingham and Solihull Intergrated Care Service 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.
1 November 2023
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Signature:
Emma Brown
Area Coroner for Birmingham and Solihull
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.
DEPUTY CHIEF EXECUTIVE’S OFFICE
22 December 2023
Coroner's Court
Steelhouse Lane
Birmingham
B4 6BJ
For the attention of Ms Emma Brown, HM Area Coroner for Birmingham and Solihull
Dear Madam
Report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 to St
Andrew’s Healthcare
1. Introduction
1.1. I write in response to the above matter and your report dated 1 November 2023. I have
been asked by the Charity’s Chief Executive,
, to provide you with a
response on behalf of the Charity. I have considered your report, spoken with colleagues
and directed further action. For the purposes of this response I will refer to St Andrew's as
"the Charity".
1.2. I would like to reassure you that the Charity is taking the issue of compliance with training
and knowledge of policies extremely seriously. It is a metric that is considered in regular
management meetings and an issue that all line managers prompt their colleagues on to
ensure training is kept up to date.
1.3. The Charity structure is designed so that there are lines of reporting and assurance between
the wards, divisions, Operational Delivery Committee, Executive Team, the Board of
Directors and the Court of Governors. The structure allows for oversight and assurance
being maintained for governance and quality activities, as well as for operational and
financial performance via the various groups and committees at various levels throughout
the Charity. I share your concern that these processes did not pick up the issues with policy
compliance in the care Mr Mishabi received in early 2023.
2. Investigations Undertaken and Explanation
2.1. In preparing this response, enquires have been made with the Clinical Director and
Associate Director of Nursing at the Birmingham Hospital.
Registered Office Billing Road, Northampton NN1 5DG
Telephone 01604 616000 Website www.stah.org
Registered Charity Number 1104951 Company Number 5176998
2.2. We have spoken with
about his knowledge of the Charity’s Pressure Ulcer
Prevention and Management Policy and we are clear that he is aware of this policy and he
has explained that he was very nervous when he was giving evidence at the inquest. I also
understand that during
evidence he did accurately describe aspects of the
policy despite him forgetting that the policy existed.
2.3. We also understand that in early 2023 when Mr Mishabi was unwell and there were issues
with his pressure ulcer management,
was on leave and not on the ward, so his
knowledge (or any actual or perceived lack thereof) of the policy will not have been a
contributory factor in the pressure ulcer care Mr Mishabi received in March 2023.
2.4. We have also enquired into the training provided to the team on Lifford ward and in addition
to the e-learning, of which you have received a copy, the Charity’s Head of Physical
Healthcare arranged in-person bespoke training on pressure ulcer management which was
attended by members of the Lifford ward team.
2.5. It also needs to be acknowledged that on Mr Mishabi’s return to St Andrew’s on 3 April 2023
the pressure ulcer care Mr Mishabi received was of a higher quality than on and around 15
March 2023. The principle reason for this appears to be due to better communication and
ownership by the physical healthcare team of the issue of Mr Mishabi’s pressure ulcers.
2.6.
, Clinical Director at the Charity’s Birmingham Hospital, has
also commented that he personally attended upon Mr Mishabi on 3 April 2023 following his
return from the Queen Elizabeth Hospital on the evening of 2 April 2023.
clinical opinion is that it the Prevention of Future Deaths Report is incorrect to
state that “Following discharge [from QEH] the ulcers proved difficult to manage and
deteriorated.”
view, which is supported by the RiO notes that you
had access to, is that Mr Mishabi’s pressure ulcers had not been appropriately treated at
QEH and he had been prematurely discharged. We can provide you with a further copy of
these notes if it would be of assistance. The discharge summary provided by QEH made
no mention of any pressure ulcers, no nursing discharge summary was provided nor had
any pressure ulcer leaflets been provided to the Charity as QEH have claimed. It is also
noted that QEH did not invite the Charity to participate in its serious incident investigation,
which may have been of assistance given there have been issues with quality of the
discharge summaries received by the Charity in relation to other patients. This is also
supported by the Charity’s Mortality Surveillance Review, which was provided to you, which
concluded:
“Mr Mishabi may have been prematurely discharged by colleagues at the QE on
2/04/23 as he was rapidly readmitted. Some liaison about how psych wards work and
that the level of fitness required to be discharged to a psych ward being equivalent to
that required to be managed in a domestic setting may be useful for QE colleagues
going forwards.”
2.7. The Charity would highlight that whilst elements of the Charity’s Pressure Ulcer Prevention
and Management Policy were not followed in early 2023, Mr Mishabi did have a pressure
ulcer prevention care plan in place as the team on Lifford ward were aware that he was at
high risk of pressure ulcers. This included ensuring Mr Mishabi had access to an airflow
bed, a pressure relieving cushion for use on his wheelchair, implementation of a turning
Registered Office Billing Road, Northampton NN1 5DG
Telephone 01604 616000 Website www.stah.org
Registered Charity Number 1104951 Company Number 5176998
regime and regular observations to prompt him to keep moving from one position. Whilst
there were deficiencies in the completion of Waterlow Pressure Scores and Skin bundles,
this had no effect on the care Mr Mishabi had access to as all the available options to limit
his risk of pressure ulcers were already in place. Mr Mishabi was also regularly reviewed
by the Physical Healthcare Team and was swiftly and appropriately escalated to the QEH
on both 18 March and 4 April 2023.
2.8. A significant change at the Birmingham hospital since Mr Mishabi’s admission is that there
is now a designated senior nursing leadership team in the form of an Associate Director of
Nursing as well as two Quality Matrons in place who have better oversight of the governance
structures designed to pick up issues such as missed Waterlow Pressure Scores. It appears
that it is not a case that the clinical governance structures are inadequate – more that the
implementation needed some refinement and support, which is now in place
2.9. Lastly, it should need to be acknowledged that whilst there were issues in early 2023 with
the Charity’s compliance with its Pressure Ulcer Prevention and Management Policy, there
is a large body of evidence that overall the care Mr Mishabi received for his physical health
was of a high standard. The team on Lifford ward worked extremely hard to manage Mr
Mishabi’s multiple physical health illnesses, namely diabetes mellitus, hypertension, end
stage kidney failure and ischaemic heart disease at times in challenging circumstances,
when Mr Mishabi’s mental disorder meant that he was not willing to follow clinical advice
that was in his best interests.
3. Actions Taken
3.1. The Charity is committed to learning from past incidents and has an ongoing commitment to
improving care standards. Despite the concerns about the nature of Mr Mishabi’s discharge
from QEH, the Charity acknowledges that there are areas where improvements are needed
based on the learning from the care provided to Mr Mishabi, an individual with complex
mental and physical illnesses.
3.2. Since Mr Mishabi’s death, a number of changes have already been implemented that have
strengthened the physical healthcare provision and the governance arrangements at the
Birmingham hospital. I would therefore highlight the following changes:
Change 1:
Structure of the Physical Healthcare Team
The physical healthcare team now comprises three nurses and the Associate
Specialist/Non-Consultant doctors, who operate under a clear escalation plan.
This enlarged team is designed to ensure a comprehensive approach to both
mental and physical health needs.
Change 2:
Improved Training for Ward Teams
Ward-based teams receive extensive training and ward managers hold
responsibility for daily observations, which include Waterlow Assessments,
Skin Bundles and NEWS assessments.
There is now extensive training provided to ward-based teams in recognising
signs and symptoms of physical health requirements.
Registered Office Billing Road, Northampton NN1 5DG
Telephone 01604 616000 Website www.stah.org
Registered Charity Number 1104951 Company Number 5176998
Change 3: Clearer Accountability and Responsibility for Physical Healthcare
Since Mr Mishabi’s death, a triumvirate leadership team consisting of
substantive postholders in the roles of Clinical Director, an Associate Director
of Nursing and a Director of Operations is now in place.
The Associate Director of Nursing has implemented robust procedures for
monitoring physical healthcare, which has set physical healthcare KPIs as a
priority KPI. The Associate Director of Nursing ensures that colleagues are
held accountable for compliance.
The Associate Director of Nursing is a physical healthcare advanced
practitioner and therefore has expertise and a professional interest in this
issue. A well-defined governance structure supports a multidisciplinary
decision-making process including Quality Matrons who are responsible for
monitoring the quality of the care provided
Change 4: Clear Escalation Plan and Daily Monitoring
A well-defined escalation process in place to address any health needs
promptly, with ward managers holding responsibility.
Regular observations, Waterlow and Skin bundles and NEWS2 assessments
conducted daily during safety huddles or divisional huddles.
Change 5:
Incident Review:
Acknowledgement of lapses in compliance with pressure ulcer prevention
policies, with a commitment to continuous training and oversight.
Change 6: Charity-wide Communication
The Charity has already sent out a reminder to all staff about the importance
of competing regular Waterlow Pressure Scores and complying with the
Charity’s policies.
3.3. In addition, the Charity is going to undertake the following additional actions:
Action 1:
Action 2:
Undertake an informal audit/dip test of the Daily Huddles
The Associate Director of Nursing will be undertaking a random sample of
daily huddles to ensure that issues with the Waterlow Pressure Scores and
other physical healthcare tests are being considered at the daily huddles.
Training
The Charity is going to ensure all staff on Lifford ward, which cares for the
patients at highest risk of pressure sores in Birmingham, receive face to face
training on pressure sores.
Registered Office Billing Road, Northampton NN1 5DG
Telephone 01604 616000 Website www.stah.org
Registered Charity Number 1104951 Company Number 5176998
4. Summary
4.1. Having considered your report, we acknowledge that whilst the Charity still has significant
concerns about the nature of Mr Mishabi’s discharge from QEH, which are not addressed in
the action plan provided to you, there are areas around the compliance with policies and the
governance processes that can be improved upon.
4.2. The Charity’s Birmingham hospital has benefited significantly by the strengthened local
leadership team and is now a significantly different service from at the time of Mr Mishabi’s
death.
4.3. I hope the additional steps outlined in this letter will provide you with some reassurance that
there is a reduced risk of future deaths following the actions that the Charity has and will
take.
Yours faithfully
Deputy Chief Executive
MB BS FRCPsych MBA FFMLM
Registered Office Billing Road, Northampton NN1 5DG
Telephone 01604 616000 Website www.stah.org
Registered Charity Number 1104951 Company Number 5176998
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