Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0428, written 6 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 | 6 Nov 2023 |
|---|---|
| Reference | 2023-0428 |
| Deceased | Madeleine Lawrence |
| Coroner | Peter Harrowing |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Bristol 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Care Quality Commission
2.
3. North Bristol NHS Trust
4. Chief Coroner
, parents of the Deceased
1
CORONER
I am Dr. Peter Harrowing, LLM, Area Coroner, for the coroner 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.
3
INVESTIGATION and INQUEST
On 31st March 2022 I commenced an investigation into the death of Ms. Madeleine
Lawrence age 20 years. The investigation concluded at the end of the inquest on 8th
September 2023. The conclusion was that the medical cause of death was I(a) Multi
organ failure; I(b) Group A Streptococcal sepsis; I(c) Streptococcal necrotising
myositis; II Traumatic native hip dislocation and the narrative conclusion was
‘Madeleine Laurence died of a rare complication of an infection which developed after
she suffered an injury whilst playing rugby. In hospital her deterioration was not
recognised and necessary life-saving treatment was not commenced promptly.
Madeleine’s death being contributed to by neglect.’
4
CIRCUMSTANCES OF THE DEATH
On 9th March 2022 Ms. Lawrence was playing rugby when she suffered a traumatic
native hip dislocation following a tackle. She was taken by ambulance to Southmead
Hospital, Bristol where underwent reduction of the dislocation under general
anaesthesia. The following day she developed pain in her hip and overnight from 10th
to 11th March 2022 her condition deteriorated. Observations were not performed for
several hours and when undertaken confirmed her NEWS score of 4. The frequency
of the observations were not increased and the provisions of NEWS toolkit and the
SEPSIS6 protocol were not followed. The NEWS score later increased to 5 and again
observations were not carried in a timely manner and prompt treatment for presumed
sepsis was not initiated.
When Ms. Lawrence was reviewed on Monday 14th March 2022 it was recognised
that she was seriously unwell and she was immediately transferred to the Intensive
Therapy Unit. She was treated for sepsis and underwent a number of surgical
procedures. Ms. Lawrence was diagnosed with necrotising myositis but despite all
efforts her condition deteriorated and she died in hospital on 25th March 2022.
During the course of my investigation I became aware that the NHS Trust had taken
steps to increase awareness and training in the NEWS toolkit and the recognition and
treatment of the deteriorating patient and sepsis in particular. The focus of the Trust’s
efforts had been the ward where Ms. Lawrence was accommodated but that training
across the wider Trust was ongoing.
1
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. –
(1) That serious deficiencies affecting the safety of patients at Southmead Hospital,
Bristol which had been identified following the death of Ms. Lawrence
(2) The CQC should confirm that it is now satisfied that the Trust has addressed the
training of current staff and has in place appropriate measures to ensure ongoing
training for new staff.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 1st January 2024. 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
Bristol NHS Trust, and the Care Quality Commission.
, parents of the deceased,North
I shall send a copy of your response to
NHS Trust
and North Bristol
I have sent a copy of my report to the Chief Coroner.
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
6th November 2023
Area Coroner
2
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.
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA www.cqc.org.uk HM Coroner The Coroner’s Court Old West Road BS48 1UL 30 January 2024 Dear HM Coroner Dr. Peter Harrowing Regulation 28 Report following the inquest into the death of Ms Madeleine Lawrence Thank you for raising the Regulation 28 report following the inquest into the death of Ms Madeline Lawrence. We have noted the matter of concern listed below. (2) The CQC should confirm that it is now satisfied that the trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff. We at the Care Quality Commission (CQC), have seen evidence of significant improvements at the trust and will continue to monitor this area. The CQC have contacted the provider North Bristol Trust to request written confirmation and evidence of the action they have taken to date, and intend to take, following the tragic death of Madeleine Lawrence. CQC also conducted an on-site assessment under the new single assessment framework on 22 January 2024 at Southmead Hospital with the focus on: learning culture • • systems, pathways and transitions and • safe and effective staffing. At the on-site assessment we found staff working across all bandings in surgical and medical wards were clear on their knowledge and responsibilities for assessing and reporting patients’ NEWS2 scores. We attended nursing and medical handovers and ward safety huddles where we found patient escalation was discussed and managed appropriately. Staff were able to clearly demonstrate the escalation process for a deteriorating patient. Staff we spoke with reported they had attended recent NEWS2 training and showed clear professional ability to apply their learning. Staff reported they could override a low NEWS2 score with clinical judgement and escalate if they were concerned about a patient, however they were not able to override a high score. 20240124_NBT_Regulation 28 Coroner response v4 On some of the wards we visited, the deteriorating patient training was highlighted as training of the month. There was easy to read information on wards for staff and weekly audits of NEWS2 compliance. The trust employed 250 internationally educated nurses last year and they had undertaken deteriorating patient training as part of their objective structured clinical examination (OSCE) preparation. The trust had created 335 senior healthcare support worker roles, with 70% having completed additional training in physiological measurement (observations) and caring for the deteriorating patient. There was a plan for this to be 100% by the end of April 2024. With regards to the ongoing training for new staff, the trust had instigated a new package entitled ‘Maddy’s Training’ which included the following subjects: • deteriorating patient • sepsis • acute kidney injury • NEWS2 This was being implemented trust wide but had not yet been fully launched. This was due to the national institute for health and care excellence (NICE) updating guidelines on suspected sepsis: recognition, diagnosis and early management (NG51) which was expected to be published in January 2024. The trust plan to amend the training to reflect the latest NICE guideline update before the launch. There were practice development nurses who were able to identify staff and refer them for further training when required. Junior doctors were on rotation every 4 months; therefore, deteriorating patient training was arranged for the intake of the new cohort. We were told bank staff had access to NEWS2 and deteriorating patient training and more explicit targets and ongoing monitoring arrangements had been established to strengthen this area. The Chief Nursing Officer had written to external agencies to reinforce the expectations of staff working at the trust. The trust had updated 3 key policies in response to patient deterioration. Acute kidney injury care had been approved in September 2023 and sepsis and NEWS2 had been approved in October 2023. We met with the senior leadership team. There was a business case for a 24 hour care rapid response team to augment ward care, with the addition of a critical care outreach service. This was progressing through the business planning process for 2024/25. A clinical lead for deteriorating patients had been appointed. They informed us that the learning from Madeline’s death had not only impacted this trust but had also been shared more widely with neighbouring trusts. The trust provided data on staff training compliance figures for sepsis, NEWS2 and management of deteriorating patients. This showed some improvement in training update compared to August 2023. Due to information migrating to a new electronic system and the implementation of revised training, the data supplied did not capture all the different methods staff received training. The trust plan to oversee the new training package with ongoing compliance versus a target percentage. We are therefore assured the trust has implemented 20240124_NBT_Regulation 28 Coroner response v4 measures to ensure ongoing training for new staff, although they are in the process of fully embedding this. CQC will monitor this position during ongoing engagement with the trust. Yours sincerely Deputy Director South Network 20240124_NBT_Regulation 28 Coroner response v4
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