Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0477, written 27 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 | 27 Nov 2023 |
|---|---|
| Reference | 2023-0477 |
| Deceased | Jennifer Whinney |
| Coroner | Melanie Lee |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Jennifer Ruth Whinney (died 2 November 2022)
THIS REPORT IS BEING SENT TO:
1. Queens Hospital
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 17 November 2022 an investigation was commenced into the death
of Jennifer Ruth Whinney aged 68. The investigation concluded at the
end of the inquest on 17 November 2023. I made a determination at
inquest that Jennifer died of multi-organ failure following septicaemia
from infective PICC lines and following successful surgery to repair a
bowel fistula. The medical cause of death was 1a. multi-organ failure,
1b. septicaemia, 1c. recurrent line sepsis, enterocutaneous fistula
repair, 2. ischaemic heart disease, hypertensive heart disease.
4
CIRCUMSTANCES OF THE DEATH
In 2017 Jennifer underwent an emergency resection of her left colon and
a stoma formation at Queens Hospital due to an ischaemic bowel. A
small area of the wound failed to heal and she was reviewed at Queens
Hospital on several occasions in 2021 and 2022. She then presented to
Queens Hospital as an emergency on 19 April 2022 when a large wound
had opened up and was discharging fluid and bowel contents. A scan
revealed a fistula. She was managed conservatively to see if the fistula
would heal by itself and this included inserting a PICC line to administer
1
nutrition so that the bowel could be rested. She had no problems with
her PICC line whilst at Queens Hospital.
She referred to the Colorectal Specialist Team at the Royal London
Hospital and seen in late May. At her initial appointment, her medical
records were not sent with her and the surgeon reviewing her only had a
referral letter.
Jennifer was admitted to the Royal London Hospital on 12 July 2022 in
preparation for surgery. She developed numerous infections to her PICC
lines which led to sepsis.
Jennifer underwent surgery to repair her bowel on 7 October 2022. The
operation was uneventful and she recovered well. She then developed a
further infection to her PICC line and died from multi-organ failure caused
by septicaemia.
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.
Jennifer was referred to the colorectal specialist team at the Royal
London Hospital and seen in late May. The witnesses were unable to
give me the exact date of the appointment. Jennifer’s notes were not sent
to the appointment with her. I heard that patient records at Queens
Hospital are not electronic. Ward staff compile the notes which are sent
physically with the patient if they attend any external appointment. I
heard that no one person has responsibility for ensuring that the notes
are sent.
Jennifer was articulate and understood her health problems well and so
was able to provide the colorectal surgeon with her medical background.
I am concerned that another patient may not be able to provide such a
full and accurate history and that critical information may not be passed
on.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that your organisation has the power to take such action.
7
YOUR RESPONSE
2
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 22 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 the following interested persons:
•
• Royal London Hospital
(Jennifer’s daughter)
And to:
• CQC
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
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 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.
9
DATE SIGNED BY ASSISTANT CORONER
27 November 2023
3
Regulation 28: Prevention of Future Deaths report
Jennifer Ruth Whinney (died 2 November 2022)
THIS REPORT IS BEING SENT TO:
1. The Royal London Hospital
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 17 November 2022 an investigation was commenced into the death
of Jennifer Ruth Whinney aged 68. The investigation concluded at the
end of the inquest on 17 November 2023. I made a determination at
inquest that Jennifer died of multi-organ failure following septicaemia
from infective PICC lines and following successful surgery to repair a
bowel fistula. The medical cause of death was 1a. multi-organ failure,
1b. septicaemia, 1c. recurrent line sepsis, enterocutaneous fistula
repair, 2. ischaemic heart disease, hypertensive heart disease.
4
CIRCUMSTANCES OF THE DEATH
In 2017 Jennifer underwent an emergency resection of her left colon and
a stoma formation at Queens Hospital due to an ischaemic bowel. A
small area of the wound failed to heal and she was reviewed at Queens
Hospital on several occasions in 2021 and 2022. She then presented to
Queens Hospital as an emergency on 19 April 2022 when a large wound
had opened up and was discharging fluid and bowel contents. A scan
revealed a fistula. She was managed conservatively to see if the fistula
would heal by itself and this included inserting a PICC line to administer
1
nutrition so that the bowel could be rested. She had no problems with
her PICC line whilst at Queens Hospital.
She referred to the Colorectal Specialist Team at the Royal London
Hospital and seen in late May. At her initial appointment, her medical
records were not sent with her and the surgeon reviewing her only had a
referral letter.
Jennifer was admitted to the Royal London Hospital on 12 July 2022 in
preparation for surgery. She developed numerous infections to her PICC
lines which led to sepsis.
Jennifer underwent surgery to repair her bowel on 7 October 2022. The
operation was uneventful and she recovered well. She then developed a
further infection to her PICC line and died from multi-organ failure caused
by septicaemia.
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.
Whilst at the Royal London Hospital Jennifer had at least 6 episodes of
sepsis from infected PICC lines. I heard evidence that these infections
were contributed to by poor PICC line maintenance. and that the
consultant colorectal surgeon raised concerns about the number of
PICC line infections that Jennifer and other patients on the ward were
getting. I heard some evidence about steps that had been taken but I
was told that it was a nursing issue and I only heard evidence from a
surgeon. I did not receive any written evidence about changes that
have been made.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 22 January 2024. I, the coroner, may extend
the period.
2
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 following interested persons:
•
• Queens Hospital
(Jennifer’s daughter)
And to:
• CQC
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
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 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.
9
DATE SIGNED BY ASSISTANT CORONER
27 November 2023
3
2 responses 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.
Private & Confidential Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 22 January 2024 Executive Offices, Trust Headquarters Queen's Hospital Rom Valley Way, Romford, RM7 0AG www.bhrhospitals.nhs.uk @BHRUT_NHS Dear Madam, Regulation 28 Report on the death of Mrs Jennifer Ruth Whinney Thank you for your Regulation 28 Report of 27 November 2023. The Trust has carefully considered the concerns raised in the learned Coroner’s report, and guidance has been sought from specialists within the Trust to address them. The matters of concern identified in the Regulation 28 report are: 1. Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queen’s Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent. 2. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on. Trust’s response: 1. A review of the process for sending patients notes accompanying them to external hospital visits has been undertaken and we have identified gaps in the governance of this. The policy has now been revised internally and the updated policy, was approved at the Policy Ratification Group that took place today, on 22 January 2024. The changes include both implicit responsibility of handing the patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. A copy of this policy is included with this response for His Majesty`s Coroner`s kind review. 2. As part of the review of transfer of health records it has been noted that medical letters detailing Name, Date of Birth, NHS number, presenting compliant, medical history, medication history and reason for referral with contact details of medical team requesting the transfer as a minimum data set should be sent with the patient and is included in the checklist detailed above. 3. The Trust is currently embarking upon its journey into digitisation of medical notes which should be completed in mid-late 2025. Once this is completed it is envisaged that the issue of medical notes being sent between hospital sites, that are also digitally enabled should be seamless; although it is recognised this is a lengthy timescale. The Trust has taken the issues identified by the Learned Coroner very seriously and has taken positive action to address them. I would be happy to meet to discuss this response if that would be helpful to HM Coroner. Yours sincerely, Chief Executive
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES www.bartshealth.nhs.uk 11th January 2024 Private & Confidential Melanie Lee Assistant Coroner Coroner Area Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Madam Lee, RE: Regulation 28 Prevention of Future Deaths Report: Jennifer Whinney I write in response to the inquest dated 17th November 2023 and the Regulation 28, Prevention of Future Deaths report to the trust dated 27th November 2023. I am sorry that the evidence of actions undertaken to reduce line infections at the Royal London Hospital (RLH) were not made available to you ahead of the inquest, but I understand was able to explain our actions during the inquest. I write further to this discussion to lay out the actions that our clinical teams are continuing to take at the RLH. I note from the feedback from the trusts legal team, that you had been informed in November 2022 that a Serious Incident (SI) investigation was to be completed. I apologise for the error in this information, it was never our intention to investigate this through the SI process and you were misinformed about this. Our staff had correctly reported it on our incident reporting system (Datix ID 399559) noting the various line infections and it has been investigated locally through that route. Ms Whinney was admitted to the RLH on the 12th July 2022 from Queens Hospital. Blood cultures were taken from her PICC line on the 12th July as part of her admission assessments. As your findings and conclusions have documented, these came back positive and were discussed with Microbiology for treatment advice on 13th July. By the 15th July she was showing the clinical signs of infection. As a result of this timeline, it was not felt that a comprehensive SI investigation was required. However, the team did recognise that there was learning and improvements to be made. We are sorry that after this time, Ms Whinney continued to experience a recurrence of line infections during her admission. Despite not completing an SI report, the clinical team did investigate the events that affected Ms Whinney, identified the source of her infection, and took actions to make improvements to the care of all their patients. In the summer of 2022, prior to Ms Whinney’s death, the surgical nursing leadership team implemented an improvement programme for the management of lines. This included a number of workstreams including: • Audit and performance - monitoring & feedback • Training and education – aimed at both nurses and medical/ surgical professions • • Ward cleaning checklists Improving staffing & retention - including nursing and ward housekeepers The introduction of a multi-disciplinary Line Infection Meeting provided a forum to share learning across departments as well as the introduction and oversight of a robust action plan started in December 2022. This action plan continues to be monitored to this day with infection control practice being regularly audited across the wards. As a note of good practice, this meeting has now expanded to be the Surgical Infection Prevention and Control (IPC) and Harm Free Care Forum, it thus incorporates a number of other aspects that all contribute to improving our patients safety and promoting a positive experience for them whilst in our care. Below is the most recent section regarding the IPC action plan for reducing infections: Issue AIM Action Line Infections ANTT To ensure particularly long line infections are clear of all known infections To ensure line infection are prevented, ensure all wards are above 85% To monitor insertion and Line care on all wards - local audit Training initiated - planning OSCE several dates planned Data will be brought about how best and what to collect ANTT project to start To monitor insertion and Line care on all wards - Local Audit ANTT technique training being agreed 5/5s (old) audit started on all wards Owner Ward 3E Staff involved All wards Nutrition team Measure of success Nutrition audits IPC audits Ward 3E All wards Nutrition team Nutrition audits IPC audits Nutrition Review of MUST scores ensure all wards above 85% To monitor compliance and actions across all wards Nutrition board Training MUST scores improving across all wards Symbiotix initiating on all wards - hostess will order - to look at who else needs training All staff are reminded about the uniform policy in daily safety briefing. Noted during the strike the 3rd floor is very cold to bring to IPC board Compliance improving staff challenging poor practice Aim to achieve at least 90% compliance with Ward manager to do spot checks on Tendable audit. weekly Matron All Wards Matron Nutrition audits IPC audits All wards All Staff Symbiotic audit results Tendable audit IPC quarterly audit results Minimise transmission of infection in the ward. Aim to achieve at least 90% compliance with Tendable audit. Aim to stay green for audit. 10e Escalated to patient ambassadors who Ward are responsible for cleaning. Still not 100% = Discussed ways in changing the schedule - rotating which half starts at 07:00am so the whole ward is focused on 15 hours of funded cleaning is required extra on ward 3D Housekeeper to check the store room Ward 3D daily. Serco Tendable audit results IPC quarterly audit results All Staff House Keeper Tendable audit results IPC quarterly audit results Aim to achieve at least 90% compliance with NIC to check if staff allocated to do the job has done the job Tendable audit. Review DSU cupboards - in place Aim to stay starting to use will feedback green for audit. improvements Educate staff the importance of the Aim to achieve at least 90% safety mechanism. compliance with House keepers to check all the bays in Tendable audit. Aim to stay green for audit. the morning. Repeat audit later this month - create list of all non-safe sharps found in our areas Not consistent, DSU improving, wards still highlighting concerns Aim to achieve at least 90% compliance with Check on weekly basis by ward manager Matron Tendable audit. Aim to stay green for audit. Ward 10E/ Chairs and tables to be cleaned daily flipped and cleaned underneath by ward hostess Met with hostess, supervisor and matron about key responsibilities and how to achieve this on each ward All wards All Staff Housekeeper Tendable audit results IPC quarterly audit results Serco Tendable audit results IPC quarterly audit results Staff compliance with bare below the elbows High dust and low dust particularly in bay areas Equipment storage Orderliness and storage (i.e., clean utility and storage area) Safety mechanism of sharps bins not being used Overfill sharps bin Patients areas clean tidy. Chair cushions and tables clean All wards All staff Tendable audit results IPC quarterly audit results Medication Management Aim to achieve at least 90% compliance with Tendable audit by IPC. Aim to stay green for audit. Moved IV medications into the locked medication cupboard. Drug prep area and storage shelving area to be included into the daily cleaning checklist. Medication trolley to be cleaned as required and checked daily NIC to check if daily temp record are complete on each shift. To ensure all drug trolleys are clean - rota implemented on wards Include pharmacist to this meeting The work implemented by the nursing staff has resulted in improvements across the surgical wards with less line infections developing. This project has been presented at the RLH Senior Leadership Forum in June 2023 led by our Chief Executive. The lines themselves were put in place in our Interventional Radiology (IR) department. The IR service also have a quality improvement programme of work for reducing the risk of line infections and I attach their action plan for your information also. Issue Aim Action Owner Staff involved Measure of success Protocol discussed in safety huddles for 2 weeks (documented in daily huddle minutes). Radiographers and Clinicians re-educated. Staff encouraged to challenge non-compliant members of team. Regular damp dusting allocation for staff and creation of cleaning record. Sister IR Team IR team fully compliant. IR IPCC Team IR team Cleanliness maintained and documented Re organisation of equipment’s in the non-critical / low risk areas. IR IPCC Team IR IPCC Team Items stored appropriately. Access for Domestics to clean all areas. Some staff not observing bare below the elbows. Staff following bare the elbow protocol. cleanliness maintained. Items stored appropriately. Access for Domestics to clean all areas. Dusts observed Regular in procedure rooms Inappropriate and mix storage of items and equipment making it difficult to clean non- critical / low risk areas Rusted trolleys/ gratnells Damaged procedure table cushion and pillows All old and rusted trolleys/ gratnells replaced. All damaged procedure table cushion and pillows replaced. All equipment’s cleaned on a regular basis with "I am clean labels". Inadequate cleaning of some equipment (i.e., ultrasound machine, etc. Regular Task allocation for cleaning cleanliness equipment and maintained. surfaces - unclear responsibilities Doors of the procedure rooms are kept open when not in use Appropriate plan for management of visitors scrubbing in Donning area prone for splash contamination Donning trolleys relocated in all rooms. Protocol in place and put into practice. All doors kept closed at all times. Identify and replace trolleys/ gratnells that will need replacing. Sister IR Nursing All old and rusted trolleys/ gratnells team replaced. Identify damaged procedure table cushion and pillows then replace. IR Team Senior Radiograp her All damaged procedure table cushion and pillows replaced. Creation of cleaning allocation and record for equipment’s. IR IPCC Team IR IPCC Team All equipment cleaned on a regular basis with "I am clean labels". Identification of responsibility owner and action maintained. Senior Radiograp her Regular cleanliness IR Radiograp maintained. hers team Action mentioned in the safety briefing and morning huddle for 2 weeks. Sister IR Nursing All doors kept closed at all times. Team Consult IPCC Team on creating a protocol/ management plan. Sister IR Nursing team Protocol in place and put into practice. Donning trolleys relocation for all labs/rooms and inform all staff. Sister IR Team Donning trolleys relocated in all rooms. The divisions continue to report progress each month to the hospitals IPC Committee chaired by the Director of Nursing (who is also the hospitals Director of Infection Prevention and Control, DIPC) and this maintains oversight of the hospital acquired infections. In May and October 2023, the Clinical Lead Dietician and Lead Nutrition Clinical Nurse Specialist completed teaching sessions at forums with the multidisciplinary surgical staff (nursing and surgical professions). These sessions included teaching about practical tips to reduce Catheter Related Blood Stream Infections (CRBSI) and the Surgical Aseptic Non-Touch Technique (Surgical ANTT) when managing surgical lines. Our Education Academy also runs an accredited surgical course for non-medical staff (nurses, midwives, and Allied Health Professionals) which includes training around line care, wound care and deteriorating patients. Furthermore, we have now updated our IPC statutory and mandatory training so that it is in line with the revised national standards. When all undergraduate medical students and junior doctors (Foundation year 1 and 2 trainees) join the trust, they undergo IV cannulation and venepuncture training which also includes ANTT training. This is part of their core teaching programme and again it follows trust guidelines. The Deputy Director of the Barts Health Education Academy is currently in the process of re- writing the ANTT policy with our microbiology and Infection Prevent and Control (IPC) teams. When launched, this multi-disciplinary policy will be embedded with training and competencies that adhere to national guidelines. It is anticipated that the final version of this policy will be ready by the end of January 2024. I hope this provides you with the assurance that we take line management and infection control very seriously and that we do have improvement work underway across the Royal London Hospital but I would be very happy to discuss or clarify any of the above points if you wished. Yours sincerely Chief Medical Officer r
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