Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0505, written 6 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 | 6 Dec 2023 |
|---|---|
| Reference | 2023-0505 |
| Deceased | John Lee |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Surrey and Sussex Healthcare 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of John LEE A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Angela Stevenson Chief Executive Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH 2 CORONER Miss Anna Crawford, H.M. Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST An inquest into Mr Lee’s death was opened on 8 December 2022. The inquest was resumed and concluded on 20 November 2023. The medical cause of Mr Lee’s death was: 1a. Choking 2. Dementia With respect to where, when and how Mr Lee came by his death it was recorded at Box 3 of the Record of Inquest as follows: Mr Lee was an 83 year old man with dementia who lived in a care home. On 17 August 2022 Mr Lee was admitted to East Surrey Hospital following a fall. By 31 August 2022 Mr Lee was medically fit for discharge, however, he remained in hospital while efforts were made to find him a more suitable care home. Whilst he was in hospital Mr Lee was found to have a newly impaired swallow, the primary cause of which was thought to be his worsening dementia, which placed him at risk of choking and aspiration. On 1 September 2022 Mr Lee was assessed by the Speech and Language Team (SALT Team) as being suitable for normal consistency foods, however, a number of recommendations were put in place to minimise the risk of choking and aspiration. These included to monitor him closely whilst he was eating and to check his mouth after eating to locate and remove any food debris. This recommendation was made because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking. On 2 September 2022 hospital staff did not complete Mr Lee’s food chart from mid-morning onwards and, as such, it has not been possible to establish what and when Mr Lee ate on 2 September 2022, save for the fact that he ate breakfast. However, Mr Lee had food residue in his stomach at post-mortem, which is consistent with him having a eaten a further meal or meals after breakfast. Overnight on 2-3 September 2022 Mr Lee was confused and agitated and repeatedly tried to get out bed. He remained agitated until approximately 3am when he settled down and went to sleep. At approximately 5.30am he was found unresponsive and his death was formally declared by a doctor later that morning on 3 September 2022. A post-mortem examination was conducted which found that Mr Lee had died due to choking on a piece of food. It has not been possible to establish precisely when on 2 September 2022 Mr Lee ate the food that he subsequently choked on. However, having eaten it, he retained it in his mouth for a period of time before subsequently choking on it. Had Mr Lee been closely monitored and provided with effective mouthcare on each occasion that he ate on 2 September 2022, in accordance with the SALT recommendations which were in place for him, he would not have choked and he would not have died The inquest concluded with a short form conclusion of ‘Accidental Death’ together with the following short narrative conclusion: Mr Lee was not closely monitored or provided with effective mouth care whilst eating on 2 September 2022. Had he been closely monitored, and provided with effective mouth care thereafter, he would not have choked and died on 3 September 2022. 5 CIRCUMSTANCES OF THE DEATH During the course of the inquest the court heard evidence from of the hospital’s SALT team that it was standard practice for dementia patients to have their mouths checked after eating, in order to locate and remove any food debris. This is because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking. However, Mr Lee’s mouth care records indicate that he had only received mouth care once daily during the entirety of his hospital stay. The Court is therefore concerned that there is a risk that dementia patients are not receiving mouth care on each occasion that they eat and that this presents a risk of future deaths. 6 CORONER’S CONCERNS The MATTER OF CONCERN is: The Court is concerned that there is a risk that dementia patients at the Trust are not receiving mouth care on each occasion that they eat and this presents a risk of future deaths. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Mr Lee’s family 10 Signed: ANNA CRAWFORD Anna Crawford H.M Assistant Coroner for Surrey Dated this 6th day of December 2023
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.
r.!1:1-1 Surrey and Sussex Healthcare NHS Trust Headquarters East Surrey Hospital · Canada Avenue Redhill RH15RH 09 February 2024 Please reply to: . · Title: Chief Medical Officer Ms Anna Crawford H M Assistant Coroner for Surrey Station Approach Woking GU22 7AP Dear Ms Crawford Regulation 28 Report- response by Surrey & Sussex Healthcare NHS Trust Inquest touching upon the death of John William Lee (Date of Birth 07/03/193~) This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to section 7(2) to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 29 September 2023, made subsequent to the inquest into the death of Mr Nickols, which was concluded on 20 November 2023. The Trust was given until 31 January 2024 to respond to the coroner, pursuant to . Regulation 29(5) Coroners (Investigations) Regulations 2013. I am very sorry for the delay in providing this response to you, it has been an exceptionally busy period in the Trust and our focus has been directed to our patients and their safe care. We would like to start this response by offering our sincere condolences to Mr Lee's family for their loss. The Trust accepts fully the findings of HM .Coroner, and that there . was failure to follow the SALT recommendations to closely monitor Mr Lee whilst he was eating and drinking, and to check his mouth after eating for items of food or debris. We are truly sorry that Mr Lee died as a result of choking on food that he had retained in his mouth, and we accept that had the SALT recommendations been followed, then Mr Lee would not have died when he did. The Prevention of Future Deaths report identifies the following area of concern, and we address this in the response, with details of the actions that we have undertaken and those that we plan to undertake, along with the details of the improvement to date that have already resulted from these actions in the appended Action Plan . The Court is therefore concerned that there is a risk that dementia patients are not receiving mouth care on each occasion that they eat and that this presents a risk of future deaths. , Consultant Admiral Nurse for Dementia to review the care I asked dementia patients receive specifically in relation to mouth care when eating and to include their dietary and swallow assessments from the time of their admission. The review included expertise from Clinical Lead for Speech and Language Therapy [SALT}; and Nurse Informatics Officer. , Mouthcare Lead; , Chief As a result of the review, the Trust identified eight actions to enhance the patient's care pathway, and ensure risks are identified and measures put in place ·to help prevent and safeguard a dementia patients' risk when eating. We intend to keep the focus on improving dementia patients care and the actions detailed below will achieve this . . To ensure patients, receive harm free and high quality nutritional care, it is vital that those patients at risk are identified and placed on the correct care plan in a timely manner. This will be achieved through the effective use of screening tools and enhancing staff knowledge. The Trust will create a Food Strategy Nutrition Steering Group which will advise the Trust on all aspects of nutrition from food provision through to intravenous nutrition support. This group will monitor numbers and trends in incidents and ensure action plans are followed through; it will seek assurance of the nutrition and hydration elements of harm free care within the Trust and provide assurance to the Board via the Quality Committee by the Chair of Nutrition Steering Group. This will ensure that the Trust's systems in relation to both food and investigations are safe. A strategy document will also be created in the coming year which sets out how the Trust will ensure that it provides safe, high quality nutritional care for all, over the next 3 years. Yours sincerely Chief Medical Officer Surrey and Sussex Healthcare NHS Trust. Enc. Action Plan 2 Action Plan Lead (Consultant Nurse Dementia) Implementation Ownership Oral Nutrition and Hydration Group Monitoring will occur via Clinical Effectiveness Committee and progress will be reported to Quality Committee and Safety and Quality Committee Action owner: (job title) Deadline for Action: Expected Improvement/ Success Measures: AUDIT RESULTS / EVIDENCE No: 1. 2. Recommendation I Issue to be addressed: Initial assessment On and during the admission staff must record concerns regarding swallowing difficulties from patient observations/report from patient/family/ carers and make referral for full assessment by Speech and Language Therapy. Patient identification/visual cues Where a patient has been assessed at risk from aspiration of food/fluid due to swallowing difficulties associate with dysphagia a clear plan is available on how to support the patient. Action(s) to be taken: Action Category Action (SMART) - Preventative Ensure where concerns regarding a patient swallow is identified a referral is made to hospital Speech and language therapy service. - Preventative Feeding plan and swallow strategies are clearly displayed by bed side of patient assessed at being at risk. New staff/ Agency/bank staff made aware during ward induction of patients with dysphagia swallowing needs Feb 2024 Re-audit June 2024 Spot audit of current inpatients with dementia, has swallowing concerns been highlighted, has a referral to Speech and Language been made, has patient been assessed and recommendations made by SALT. Any swallowing concerns appropriately identified/ Appropriate referrals made from ward, Referral picked up and seen by SALT in a timely Feedback to the wards/clinical areas if any issues or new learning identified and using Feb 2024 Re-audit June 2024 Spot audit in clinical areas to ensure that patients identified at risk of swallowing due to . dysphagia. That swallow plans are clearly visible in hand over document and on patients' bed Clinical Audit and quality improvement methodology to be used to drive improvement until audit standards are met. Audit tool used and feedback to clinical area team of concerns and good practice. 3 3. To ensure that this is communicated and documented at ward handovers/ huddles. Mouth care matters on Cerner Review mouthcare documentation on Cerner with the electronic patient record team. 4 Mouth care matters . Staff complete mouthcare sections correctly on Cerner Mouth care recommendation for patients who have been identified as a swallowing risk due to dysphagia Corrective Mouth care Review and recommend changes to electronic recording of mouth care matters on Cerner. This wil l include Initial assessment to establish base line. Directive Mouth care Nurse rounding section (Asist with food/fluid/mouthcare) Record if assistance offered and accepted, declined etc . June 2024 Improved record ing of mouth care matters on Cerner Correct Cerner documentation in place and staff aware of where to record mouth care Improved recording of Dec 2024 (dependent mouthcare assessment on Cerner being updated) and provides evidence that Cerner of patients with mouthcare needs have been met. dysphagia (from Cerner list of patients with Dysphagia) Complete audit of use of Mouth care recording on 5. SALT to continue with Preventative Promote increased Swallow awareness training rolling programme across wards awareness of swallowing difficulties and SALT strategies with supporting patients identified with swallowing difficulties and April 2024 SALT team Audit how many wards have undertaken training Improved staff knowledge and awareness of dysphagia Feedback to Matrons wards that have participated in training and identify areas that need refresh training . Gain feedback from staff by through use of staff survey to measure success of training . 4 Diary rolling programme of training across clinical areas 6. Swallow awareness event Preventative "Remember Dysphagia" Nutrition awareness 11- 17 March and swallow awareness day nutrition week March 2024 7. Review Meal time policy Preventative 8. (Oral Nutrition and Hydration policy) Red Tray guidance relaunch (policy being updated) discussed at nutrition steering group. Preventative Promote swallow awareness as part of swallow awareness day "Remember Dysphagia" and SALT team March 2024 Events ·and commutation (infographics etc) will be available as part of swallowing awareness day Improved staff and general population knowledge and awareness of dysphagia Materials produced , information stand . Internal and external communications promoting Dysphagia awareness. Carry out staff survey to measure success of event. March 2024 March 2024 Updated policy ·improving the importance of protective meal times, Patients receive a better meal time experience Raised staff awareness about use of red trays. Spot audit of use to ensure red trays are being used appropriately ' Updated policy, Evidence from PLACE Audit Evidence from audit and feedback to ward staff and matrons. Review evidence from PLACE Aud it Review Meal time policy to ensure it reflects current practice As part of Meal time policy review use of red trays for all patients with additional needs and requiring extra attention when eating , or heed foods that have a modified texture. (Clinical lead for dietetics) (Clinical lead for dietetics) Matrons ward staff 5
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