Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0017, written 5 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 | 5 Jan 2024 |
|---|---|
| Reference | 2024-0017 |
| Deceased | Tammy Watkins |
| Coroner | Laurinda Bower |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Nottinghamshire Healthcare 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust 1 CORONER I am Miss Laurinda Bower, HM Area Coroner for the coroner area of Nottingham and Nottinghamshire 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 13 October 2021, I commenced an investigation into the death of Tammy Mary Louise WATKINS, aged 36, which concluded by inquest held before me sitting with a Jury between 9 and 20 October 2023. The Jury recorded a Narrative Conclusion detailing multiple failings in Tammy’s care which probably more than minimally contributed to her death. The Jury found that Tammy’s death was contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH Tammy Mary Louise Watkins was detained pursuant to s.45(5) of the Mental Health Act 1983 at the Women’s High Secure Service, Rampton Hospital, Nottinghamshire, when she swallowed a plastic twistable crayon (approx. 17 – 20cm in length), which perforated her bowel, causing her death on 6 June 2021. Tammy was assessed as being at high and ongoing risk of ingesting foreign objects, a risk which had materialised on many occasions prior to her death, and often lead to hospital admission. Her risk of self-harm by ingestion led to the lawful use of mechanical restraints, comprising of mittens, a bio belt, eyesight or arm’s length observations, controlled and supervised access to items when spending time out of her mittens, and a total restriction on Tammy having free access to personal items. On 22 March 2021, hospital staff provided Tammy was a twistable crayon to use while her mittens were removed. The twistable crayon had not been risk assessed or approved for use by Tammy’s MDT, who were responsible for setting her care plan. In those circumstances, the twistable crayon ought not to have been provided to her. If the crayon had been presented to the MDT, her Consultant Psychiatrist would not have approved its use as it would have posed an obvious risk of serious harm if ingested due to its size and plastic structure. Instead, alternative child-safe small wax crayons could have been used to meet the same therapeutic purpose. At this time, the Trust did not have any documented system that set out the requirements for the MDT to approve the use of risk items, but this was nevertheless an expectation on the MDT, which they failed to complete. There is no clear or consistent record of who was observing Tammy or what items she had been granted access to on 22 March 2021. Despite the crayon being noted as “missing” from the pack, no incident report was completed, nor was the Security Manager alerted or any ward level plan initiated to seek to locate the risk item. Tammy started to present with symptoms of a complication of swallowing the item the next day. She reported nausea after eating, vomiting and epigastric tenderness. Mental health staff escalated her Regulation 28 – After Inquest Document Template Updated 30/07/2020 symptoms to the physical healthcare team. Tammy reported to the Advanced Clinical Practitioner that she could feel the twistable crayon inside her. The ACP made a plan to monitor for any deterioration and to discuss with the GP the following day. She was not escalated for investigations at the local hospital despite the size of the missing item and Tammy reporting feeling it inside her. The Trust failed to have in place a formal policy relating to the management of the ingestion of foreign bodies. This meant that staff were not all working to a clear plan of how to monitor for, detect and respond to the medical complications of ingesting foreign bodies. The MDT failed to have in place a care plan specific to Tammy’s risk of swallowing, setting out how this should be managed and escalated by ward staff. There was no continuing, co-ordinated investigation to seek to locate the twistable crayon. On the evening of 16th May 2021 Tammy was observed to be vomiting in her toilet and at the same time reaching into the toilet. When asked, Tammy reported that she had swallowed a toothbrush. An out of grounds visit was arranged to take Tammy to Bassetlaw District General hospital. Tammy was examined at Bassetlaw General Hospital and was given an x-ray at 01:33am on 17th May 2021 which did not reveal any foreign bodies. Tammy was booked for an ultrasound scan later that day but was discharged at approximately 9:30am and returned to Rampton Hospital before this could be completed. Staff seem to have taken the negative x-ray result as evidence that there were no foreign bodies in Tammy’s system. Many staff were unaware of the limitations of x-ray in relation to non-radiopaque items or the extent of the imaging. On the evening of 4th June 2021 Tammy reported discomfort and anxiety due to constipation. Given the timing and symptoms we feel this is likely to be the beginning of Tammy’s deterioration. No actions beyond further observations are recorded to have taken place, staff appear to have taken Tammy’s constipation entirely at face value. There is no evidence that the twistable crayon was being considered at this point. Tammy spent most of the day of 5th June 2021 in bed due to worsening symptoms. It is recorded that a mechanical restraint review was undertaken by the duty doctor, but it is unclear whether any physical examination of Tammy was undertaken at this point. By the evening of 5th June Tammy’s temperature and heart rate had begun to spike and mental health staff became concerned. The same duty doctor was contacted during the evening by ward staff as Tammy continued to deteriorate. The duty doctor did not attend the ward or examine Tammy and advised ward staff to provide Tammy with paracetamol. This represents a missed opportunity to have recognised the deteriorating patient and to have sought medical attention. There is no record at this point that Tammy’s symptoms were linked in any way to foreign body ingestion, despite Tammy voicing concern that she may have perforated her bowel. Tammy’s symptoms continued to worsen throughout the early hours of 6th June 2021, including high pulse rate and temperature, anxiety, abdominal pain and vomiting, escalating to projectile vomiting and apparent ‘faecal’ vomit. The Hospital Trust failed to adhere to the NEWS2 Policy when Tammy was acutely unwell. NEWS2 was not recorded as frequently as required, at times the readings were incomplete, and the total score was not acted upon in accordance with the policy. This led to an underestimation of Tammy’s clinical risk, and multiple missed opportunities to have rendered care in an acute hospital which would probably have prevented her death The physical healthcare team and the on-call Duty Doctor failed to recognise Tammy was a deteriorating patient and failed to take steps to arrange her timely transfer to an acute hospital for treatment of her perforated bowel. Over the weekend of 5-6 June 2021 there was a breakdown in communication between the ward staff, physical healthcare staff, duty doctor, and site management as to Tammy’s signs and symptoms which led to a delay in her being transported to hospital to receive treatment for her condition Tammy continued to deteriorate throughout the morning of 6th June 2021, until shortly after 2pm when Tammy’s symptoms were recognised by the physical healthcare team to be so severe that an ambulance would be required to take Tammy to hospital. A number of miscommunications between staff, added to the lack of a clear escalation protocol for staff to follow, resulted in a delay to the ambulance being called, because staff were unclear who should call the medical emergency. The Hospital Trust accepts that multiple failings in Tammy’s care probably more than minimally contributed to her death. Neglect contributed to her death. Regulation 28 – After Inquest Document Template Updated 30/07/2020 5 CORONER’S CONCERNS During the course of the inquest I heard evidence 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. Poor Quality Acute Physical Healthcare in the mental health setting Tammy’s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention. Her death comes after repeated concerns have been raised about the quality of the Trust’s physical healthcare service in secure settings since 2018 (when Angus Bowie died from sepsis due to a perforation), in 2019 (when Christopher Howard Smith died from a pulmonary embolus), in 2020 (when Alexander Braund died from a chest infection) and in 2021 (when Michelle Louise Whitehead died from Hyponatraemic Encephalopathy). At each of those inquests, the Trust committed to improving the quality of physical healthcare across all secure settings and yet the same poor quality has prevailed in Tammy’s care. These are examples of preventable deaths and the similarity in themes across them is exceptionally worrying. Action needs to be taken at the most senior level to effect meaningful change to the quality of physical healthcare across all secure settings at which the Trust provides services, recognising this class of patients as exceptionally vulnerable to deterioration as they are unable, either through mental health challenges and/or incarceration, to access healthcare services of their own volition. 2. Failure to Adhere to the National and Local National Early Warning Score (version 2) Policy This is a repeated theme identified at inquest and in previous Prevention of Future Death reports. Staff remained unclear at the inquest about how frequently vital signs ought to be taken, where and how to record the values, and what action should be taken depending on the score. 3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. 4. Emergency Medical Calls There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service. It had been recognised early in the day by the Security Team that Tammy may require an out of grounds medical transfer, but it was not until much later in the afternoon, when Tammy was in cardiac arrest, that an ambulance was called. The Security Team expected the physical healthcare team to place the call, the physical healthcare team expected the ward to place the call due to proximity to the patient. Evidence called at the inquest established continued confusion amongst staff as to how an emergency should be managed. This appears to be a training issue. Regulation 28 – After Inquest Document Template Updated 30/07/2020 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 4 March 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 -Tammy’s Family Doncaster and Bassetlaw NHS Trust I have also sent it to - Nottinghamshire Police Care Quality Commission Health and Safety Executive NHS England as Commissioners for the healthcare services subject to this report who may find it useful or of interest. 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 Dated: 5 January 2024 Miss Laurinda Bower HM Area Coroner Nottingham and Nottinghamshire Regulation 28 – After Inquest Document Template Updated 30/07/2020
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.
Nottinghamshire Healthcare NHS Foundation Trust Duncan Macmillan House The Resource Porchester Road Mapperley NG3 6AA Monday 4 March 2024 Private and Confidential HMC Bower Dear HMC Bower RE: Preventing Future deaths Response, Tammy Watkins Further to the Inquest into the death of Miss Tammy Mary Louise Watkins, I write in response to the Prevention of Future Deaths order Nottinghamshire Healthcare NHS Trust were issued with on the 5 January 2024. Ms. Watkins died on the 6 of June 2021 at Bassetlaw having been a patient at Rampton High Secure Hospital. We accept the findings from the Inquest and would like to assure you that we take the findings and actions very seriously and provide the updates below in response to your concerns: 1. Poor Quality Acute Physical Healthcare in the Mental Health Setting The Trust recognises that Physical Healthcare is a key quality priority to improve the care to patients and reduce the risk of harm. The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated training needs and structure of who provides what care across the inpatient services to mitigate future harm associated with the deteriorating patient. The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Active work has commenced in Adult Mental Health inpatient services and Rampton Hospital and will continue to roll out across all services over the next 12 months. The work is informed by best practice, the needs of the patient group and learning from the thematic reviews of incidents of past harm, alongside learning from staff in practice. The work is overseen in the Trust Physical health strategic group and is overseen by the Quality Operational group and Committee. The output of the review will be the development and delivery of a Trust Physical Healthcare Strategy which will sets out and defines clear roles, responsibility, and accountability within the framework. The strategy will include both internal and external stakeholders such as local Acute and General hospitals that our patients access whilst an inpatient at Rampton Hospital to ensure best possible outcomes. Working collaboratively will ensure improved communication and enable practitioners to work together with a shared approach, incorporating a system wide response. The oversight, leadership and governance of physical health care will also be reviewed and amended accordingly. We would be happy to share this work and the key findings and actions with HM Coroner to show the progression and development of this work. 2. Failure to Adhere to the National and Local National Early Warning Score (version2) Policy. NEWS 2 was introduced in the Trust in 2020. We recognise that the implementation has been more complex and additional improvement support has been implemented to address these gaps. NEWS 2 training has been delivered to all frontline clinical staff who would be required to undertake this assessment and supports the policy requirements. In addition to this, at a glance posters are within each of the inpatient wards alongside lanyard attachments to support easy to access guidance when undertaking a NEWS2 assessment. A full audit process around NEWS2 is now in place and is monitored and responded to within normal governance frameworks with current compliance at 98%. Rampton hospital have ensured that senior nursing staff have increased visibility and presence in patient facing areas, to provide’ in action’ learning, role modelling and opportunity to provide direct feedback to colleagues. Clinical supervision is also recognised as a key aid to supporting and developing practice by sharing feedback and providing one to one clinical input to improve practice and aid a culture of learning. Having senior Quality Matrons deliver and provide clinical supervision further strengthens this approach and encourages a culture of continuous learning and improvement. Quality Matrons will use clinical supervision to introduce scenario-based examples of patients who require escalation to assess staff members competency around NEWS2. The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA A further training needs analysis is currently being undertaken to understand if this can be enhanced to support and improve front line knowledge and clinical skills. HM Coroner will be updated as this moves forward. 3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approvals group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present. To review current practice and to continue to address areas of concern, Rampton Hospital are undertaking case reviews of subsequent similar presentations to identify if the learning from Tammy’s death has been embedded and sustained. We will ensure that any learning or areas for continued training are identified within these case reviews are responded to and included within Hospital Life Support training/ any future enhanced training that is provided. A comprehensive learning event was held on the 5 February 2024 this included a wide range of clinicians, managers clinical leaders and frontline staff, this event shared and discussed the outcome of the PFD with a specific focus on the risks associated with ingestion behaviours, barriers, improved partnership working and a solution focused approach to reducing and mitigating this risk wherever possible. 4. Emergency Medical Calls The process for emergency medical calls within Rampton Hospital has been reviewed and the process has been reenforced back to all staff that where immediate concerns are present regarding the physical health of a patient, it is expected that they will call for an ambulance. This is reviewed in line with the increased senior leadership and local learning. The development of the Physical Health Strategy will further complement this work as the key aim is to ensure staff are clear on the remit of their roles and what actions they are accountable to take when a patient is deteriorating. I hope that the information contained within this response provides assurance to you and Ms. Watkins’s family that we, as a Trust have heard and understood the significant concerns raised throughout and as a consequence of this inquest, and that we are committed to continuing to make these important improvements to services and processes for future patient care. The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Yours sincerely Executive Director for Nursing, AHPs & Quality The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
See every Prevention of Future Deaths report matching Nottinghamshire Healthcare NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.