Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0501, written 4 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2023 |
|---|---|
| Reference | 2023-0501 |
| Deceased | Catriona Martin |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| 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.
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 THIS REPORT IS BEING SENT TO: The Chief Executive of Aneurin Bevan University Health Board. CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 On 19/01/2021, an investigation was opened into the death of Catriona Ellen Martin The investigation concluded at the end of the inquest on 23/11/2023. The conclusion of the inquest was recorded as a narrative conclusion in the following terms: Catriona Ellen Martin was admitted to hospital on 05/12/2020 with autoimmune encephalitis. The treatment plan was not adhered to because Catriona was not provided with adequate nursing care which resulted in a failure to observe her, failure to administer medication and caused her to develop dehydration, acute kidney injury and uncontrolled seizures. This resulted in Catriona’s death at the Grange University Hospital, Llanfrechfa on 25/12/2020. Catriona Ellen Martin died from the effects of autoimmune encephalitis contributed to by neglect. The medical cause of death was: 1a) Autoimmune encephalitis 4 CIRCUMSTANCES OF THE DEATH The circumstances of Catriona’s death are best described in the narrative conclusion. Throughout her admission Catriona required 1:1 nursing care which, apart from a short admission to ITU between 08/12/2020 and 15/12/2020, Catriona did not receive. The nursing staff relied on Catriona’s mother to ensure that Catriona received the fluid and medication she required. Catriona’s mother continuously advised the nursing staff that she was unable to ensure that Catriona was receiving fluid and medication, however no assistance was given, and Catriona went into a fatal decline. I found that Catriona’s death would have been prevented if 1:1 nursing care had been provided. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - At the inquest I determined that the level of care that Catriona’s mother was expected to provide was unacceptable but was informed that there are no guidelines to establish the level of delegation of nursing duties in such circumstances, and the requirement of the nursing team to not only continue to supervise care but to support and intervene as required. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: All guidelines and policies regarding the delegation of nursing responsibilities to family members when these are tasks that the family do not normally provide and for which they have had no training. Note, this is separate to the care provided in hospital by regular community carers or family members who undertake these tasks at home and are cognisant of the patient’s normal needs and requirements. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 29/01/2024. I, the Coroner, may extend this period. 8 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 necessary. COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Catriona Martin 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 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 DATE 4/12/2023 Signed: Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
Our ref: NP/kh 29 January 2024 Caroline Saunders Senior Coroner (Gwent) Dear Ms Saunders Re: Re; Aneurin Bevan University Health Board response to Regulation 28 Report received following the inquest touching on the death of Catriona Martin Thank you for your letter of 4th December 2023 and accompanying report, which the Health Board received on 5 December 2023 I am writing to provide you with the Health Board’s response to the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Catriona Martin As requested, the information presented below is intended to describe the actions which have been taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future deaths. You require the Health Board to provide you with the following information: All guidelines and policies regarding the delegation of nursing responsibilities to family members when these are tasks that the family do not normally provide and for which they have had no training. Note, this is separate to the care provided in hospital by regular community carers or family members who undertake these tasks at home and are cognisant of the patient’s normal needs and requirements. Firstly, the Health Board wishes to make clear that no family member should be requested to undertake tasks or provide care to patients if this is not something they normally provide, wish to continue providing or the patient has not consented to. Care planning and the delivery of care must be personalised and assessed on an individual basis and any delegation of care must be considered as appropriate, safe and mutually agreed with patients, families and nursing staff. In August 2021, the Health Board developed and then launched a Person-Centred Enhanced Observational Framework. The purpose of the framework is to provide personalised, appropriate, consistent and high-quality enhanced observation/care for those patients deemed appropriate to receive such care requirements. The person-centred enhanced observation framework incorporates an individual management plan and tool kit which assesses a patient’s needs and supports the delivery of care to provide safe and dignified patient centred care. Bwrdd Iechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ Aneurin Bevan University Health Board Headquarters, St Cadoc’s Hospital Lodge Road, Caerleon, Newport NP18 3XQ 01633 436 700 BwrddIechydPrifysgol BIPAneurinBevan 01633 436 700 AneurinBevanHealthBoard AneurinBevanUHB Rydym yn croesawu gohebiaeth yn Gymraeg a byddwn yn ymateb yn Gymraeg heb oedi. Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan. We welcome correspondence in Welsh and we will respond in Welsh without delay. Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board. Supported by the patient centred care team the framework has been rolled out across all acute and community wards to ensure patients requiring a level of enhanced observation and supervision, either through an increase in observation, cared for in a cohorted environment or requiring 1:1 nursing care, are identified and appropriate care and observation initiated. The framework includes: A description of the different levels of enhanced care, and the enhanced support and observation required to deliver each level of observation. A detailed personalised management plan which includes: − individual care planning around environment, agitation, pain, infection, nutrition, constipation, hydration, medication, sleep and risk of falls. Enhanced observation review documentation to determine whether enhanced care requirements have changed, whether there is a need to escalate/de-escalate. Behaviour charts which also determine trigger points which may require escalation. Person centred meaningful activity chart Enhanced care staff rotation record Patient centred enhanced observation information leaflet. Following the raising of the matters of concern, it is recognised that additional training and education is required to ensure staff are clear in their responsibilities in regards appropriate delegation of care to family members. This can include patient care that is not only prescribed through cognitive impairment but is associated with acuity and complexity associated with intervention such as, post operative procedures. Education and training will be delivered via Patient Safety and Quality focused study sessions, supported by a bespoke programme of work with the Person-Centred Care Team. Throughout this work increased emphasis will be placed on appropriate and safe delegation, family involvement and utilising the framework not only for those patients with cognitive impairment but for those patients with complex medical acuity. The Health Board is currently in the process of revising the Person-Centred Enhanced Observational Framework. The revised version will include the following requirements to be documented: A conversation with family members on expected levels of care delivery and involvement. Levels of delegation and the responsibility of the registrant to deliver care and assessment to the patient meeting their individual needs in collaboration with family. Documented evidence which demonstrates that the care plan has been developed in collaboration with patients (if able to do so) and family. Learning implemented to date and future plans: HealthRoster SafeCare is a digital platform that has been introduced and currently being rolled out across the Health Board. SafeCare gives nurses the visibility of staffing levels across wards and departments, allowing them to maintain safe and compliant patient care based on patient numbers, acuity and dependency. It supports day-to-day operational changes to the roster in real time, facilitating the redeployment of staff to support enhanced care requirements. The system enables a review of daily staffing levels and whether they are deemed safe to meet clinical demand. SafeCare provides the functionality to enter acuity and/or dependency data to inform evidence-based decision making on staffing requirements and workforce. This provides a visual platform of establishments, skill mix, patient demand/acuity in real-time to ensure informed decisions are made and supports acuity-driven staffing level requirements. 2 An ‘Educational and Recommendations After Significant Events (ERASE) Poster’ to raise awareness and share learning, specific to this case, has been developed and disseminated. This case has been discussed and outcomes shared widely. Delegation of care, documented conversations with family members and the importance of clear concise communication with families and friends has been reinforced ensuring clarity is gained in regards family involvement in patient care. I trust that this information provides assurances in regards the matters raised. However, if any further information or assurance is required, please do not hesitate to contact me. Yours sincerely Chief Executive 3
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