Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0006, written 4 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2024 |
|---|---|
| Reference | 2024-0006 |
| Deceased | Elizabeth Roberts |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation 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. Secretary of State for Health and Social Care 1 CORONER I am Lauren Costello, Assistant Coroner, for the Coroner Area of Manchester South 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 24th May 2023 an investigation was commenced into the death of Elizabeth Roberts then aged 91 years. The investigation concluded at the end of the inquest on 19th December 2023. I recorded a narrative conclusion that Mrs Roberts died from sepsis with congestive cardiac failure due to underlying ischemic and valvular heart disease with the superimposed physiological burden of sacral ulceration on a background of severe frailty. The medical cause of death being: 1a. Sepsis with congestive cardiac failure 1b. Ischaemic & hypertensive heart disease with superimposed sacral ulceration on background of severe frailty 1 4 CIRCUMSTANCES OF THE DEATH Mrs Roberts was severely frail and bedbound with urinary and faecal incontinence. She had ischaemic and hypertensive heart disease and developed a large sacral sore with associated sepsis. These conditions precipitated congestive cardiac failure. She was admitted to Tameside General Hospital on 19th May 2023 where despite treatment, she died the same day of Sepsis with congestive cardiac failure. The inquest heard that Mrs Roberts was supported by care agency carers four times per day and the District Nursing Team. Following a Tissue Viability assessment on 20th April 2023 the frequency of visits by the District Nursing team was increased to daily until Mrs Roberts was admitted to Tameside General Hospital on 19th May 2023. The Inquest heard that the care agency raised concerns with Adult Social Care because her dressings were not being changed daily. In addition, Mrs Robert’s family raised concerns as did the hospital nurse responsible for Mrs Robert’s care on 19th May 2023. As a result, an investigation was opened by the District Nursing Service. The Inquest heard that insufficient dressing changes for a sacral sore can lead to localised and systemic infection due to the risk of a sore in that area of the body being contaminated with urine and faeces. The family were told on several occasions that the nursing team did not have time to change dressings. On 17th May 2023 a nurse did not attend to care for Mrs Roberts due to demands upon the District Nursing Team. The team offered instead an out of hours visit that would have disturbed Mrs Roberts and her family from sleep and so this was not accepted. The Inquest heard that there are ongoing staffing issues within the District Nursing Team. Following the Serious Incident Investigation, a number of measures have been undertaken by the Tameside and Glossop Integrated Care NHS Foundation Trust to address issues identified with the care of Mrs Roberts and with the district nursing service generally including: Introduction of weekly compliance checks for Waterlow, MUST and body mapping policies. All District Nursing Visits deferred to the out of hours service must be approved by Sister of Team leader. However, the Inquest heard that despite a number of steps taken locally to manage the District Nursing Service such as using a variety of different staffing grades for visits, staffing shortages cannot be rectified by local action without a change of approach nationally. 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 could 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) Despite a number of measures being undertaken by Tameside and Glossop Integrated Care and NHS Foundation Trust, the Inquest heard that there are residual staffing shortages in the District Nursing Service which the Trust is unable to resolve without a change of approach nationally. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and have 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 29th February 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 Chief Coroner and to the following Interested Persons: , legal representative for the Trust 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. 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 Lauren Costello HM Assistant Coroner 4th January 2024 3
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.
From Helen Whately MP
Minister of State for Care
39 Victoria Street
London
SW1H 0EU
Lauren Costello, Assistant Corner, for the Coroner Area of Manchester South
Coroner's Court
1 Mount Tabor Street
Stockport
SK1 3AG
25 April 2024
Dear HM Assistant Coroner Costello,
Thank you for your letter of 4 January 2024 about the death of Elizabeth Roberts. I am replying
as the Minister with responsibility for Community Health Services.
Firstly, I would like to say how saddened I was to read of the circumstances of Elizabeth
Robert’s death, and I offer my sincere condolences to their family and loved ones. The
circumstances your report describes are very concerning and I am grateful to you for bringing
these matters to my attention.
The report raises concerns about residual staffing shortages within the District Nursing Team.
In preparing this response, Departmental officials have made enquiries with NHS England.
We recognise the importance of identifying the correct staffing levels in community health
care. NHS England has developed a national Community Nursing Safer Staffing Tool which
is being offered to community nursing providers to support them with identifying whether
they have the right staffing levels in order to deliver care safely to those people in their care.
This can help to identify gaps in the service and enable strategies to be developed locally to
manage and address the shortfall.
In regard to system and local assurance, the region have asked Greater Manchester
Integrated Care Board to discuss the case further within their System Quality Group to identify
any further actions that need to be taken. I have asked NHS England for an update once
actions have been identified.
Nationally, we have taken steps to increase nurse numbers and in September 2023 we met
our commitment to delivering 50,000 more nurses working in the NHS compared with
September 2019.
In addition, as of January 2024, there were over 68,800 full time equivalent community nurses
working in NHS trusts and other core organisations in England. This is over 2,100 (3.2%) more
than a year ago.
The NHS Long Term Workforce Plan (LTWP) sets out the case for the long-term change for
the NHS workforce and outlines plans to address an expected shortfall. The LTWP sets out
the steps the NHS and its partners need to take to deliver an NHS workforce that meets the
changing needs of the population over the next 15 years. The plan recognises the shortage
of district and community nurses, and this is a priority for the national workforce team to
address. The plan sets ambitions to increase training places for district nurses by 150%, to
nearly 1,800, by 2031/32.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours,
HELEN WHATELY
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