Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0112, written 28 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2024 |
|---|---|
| Reference | 2024-0112 |
| Deceased | Gillian Baumgardt |
| Coroner | Simon Fox |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Bristol 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.
M. E. Voisin His Majesty’s Senior Coroner Area of Avon 28th February 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: North Bristol Trust 1 CORONER I am Dr Simon Fox KC, Assistant Coroner for Area of Avon. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 20/12/22 an investigation was commenced into the death of Gillian Baumgardt. The investigation concluded at the end of the inquest on 27th February 2024. The conclusion of the inquest was – “Mrs Baumgardt died in part because she underwent wrong site hip surgery due to multiple errors occurring in the performing and reporting of a plain x-ray of her hip”. 4 CIRCUMSTANCES OF THE DEATH Mrs Baumgardt was an elderly lady with dementia who fractured her right hip at home. She was admitted to your hospital and diagnosed correctly with a suspected fractured right hip. However, in then performing and reporting the plain x-ray of her hips the following errors occurred – Radiographer – Pre-exposure marker not placed in film field; - - Digital image inadvertently flipped; - Digital image mislabelled left/right so that fractured side recorded as left; - - Normal x-ray of left hip did not alert to error and did not lead to the affected side being double Cross on image denoting flipped not detected; checked; Radiologist – - Normal x-ray of left hip attributed to error in labelling, rather than alerting to error and leading to the affected side being double checked. Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL As a result Mrs Baumgardt was referred to the orthopaedic team erroneously as presenting with a left hip fracture. Her age and dementia were such that she was difficult to assess clinically, the orthopaedic surgeons had no reason to suspect an error in labelling and she underwent surgery removing a healthy left femoral head. The error was then appreciated and she had to undergo surgery to the right fractured hip 2 days later. She died 6 weeks later having never regained her mobility. I found on the evidence that the wrong site surgery contributed to her death. 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. – (1)Accurate radiology is essential to avoid wrong site surgery in elderly patients with dementia suffering hip fracture; (2) There is no system requiring radiographers to ensure that pre-exposure markers are present in the x- ray field in all such patients; (3) There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients. Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 26th April 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 Mrs Baumgardt’s family. 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 28/02/2024 Dr Simon Fox KC, Assistant Coroner Area of Avon. Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
rt!1:b1 North Bristol NHS Trust Trust Headquarters Gate 3 Level 2, Brunel Building Southmead Hospital Westbury-on-Trym Bristol 8S10 SNS Website: www.nbt.nhs.uk HM Coroner's Service Coroner's Court Old Weston Road Flax Bourton 8S48 1UL 24 May 2024 Dear Dr Fox Re: Regulation 28 Report following the Inquest into the Death of Mrs Gillian Baumgardt I write further to the Regulation 28 Prevention of Future Deaths Report, dated 28 February 2024, issued as a result of the inquest into the death of Mrs Gillian Baumgardt. The Regulation 28 raised two key concerns, namely:- 1) There is no system requiring radiographers to ensure that pre-exposure markers are present in the X-ray field in all such patients (elderly patients with dementia suffering hip fracture); 2) There is no system requiring rad iologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients. North Bristol NHS Trust offers the following responses to the points raised: 1) No system requiring radiographers to ensure that pre-exposure markers are present in the X-ray field of elderly patients with dementia suffering hip fracture At North Bristol NHS Trust it is a requirement that 100% of X-Ray images have an anatomical side marker. The Gold standard is for these to be pre-exposure markers. By way of background information, the use of pre-exposure markers involves the mechan ical placement of a small metal marker onto an X-Ray detector or the patient, and it is a practice that is subject to a small failure rate. Dependent on the configuration of the patient or the Imaging equipment (patient standing or lying on X-Ray table, or X-Ray on emergency trolley) then the placement of any such marker will differ in its technical application . When the marker is physically placed on, beside, or beneath the patient, there is a possibility that the marker may move as the patient readjusts their position due to pain or discomfort attributed to their injury or illness. When the marker is placed on the detector, the marker may fail to show due to misalignment of the detector to the collimated (confined area) of the X-Ray. These occurrences have been observed as findings in our audit of side markers since October 2022. It is therefore important to recogn ise that in a small proportion of images the pre-exposure marker will be absent, and a decision is made on how to rectify the situation and provide an image that is A University of Bristol Teaching Trust. A University of the West of England Teaching Trust. rt!1:b1 North Bristol NHS Trust populated with an accurate side marker. In this small proportion of situations, if the Radiographer has confidence on the radiographic positioning, image orientation, and equipment parameters then at North Bristol NHS Trust a requ irement to repeat the X-Ray is not deemed necessary. This is based on considerable systems training for the Radiographer, both at North Bristol NHS Trust and during undergraduate training. The decision is also informed with consideration to the Ionising Radiation (Medical Exposure) Regulation guidance on keeping the X-Ray dose to the patient to as low as reasonably practicable. Repeat imaging occurs only in those instances of clinical uncertainty. Since December 2023, the Plain Imaging department at North Bristol NHS Trust has introduced a process for checking the placement of an electronic (post exposure) marker in trauma radiographs. This is a buddy check type system, where a Radiographer colleague will record a signature to evidence they have checked the post-exposure electron ic marker is accurate both in its selection and position on the X-Ray image. This method introduces a pause and check prior to the submission of X-Ray images. The signature is recorded on a Trust approved document (copy enclosed) for undertaking patient checks during X-ray procedures and it is thereafter scanned into the patient notes. In addition, we have introduced a daily audit for the checking of trauma hip radiographs (in combination with the existing w ider departmental audit of pre-exposure markers) providing a real focus on X-Ray Imaging for this patient group and presenting the opportun ity to intervene should errors be noted and provide timely feedback for improvement when non-compliance is detected . Lead Radiographer Paul Hocking commenced this audit on 4 March 2024. Since then, this audit has evaluated over 1700 hip X Ray images, all of which have been accurate in positioning , all w ith an anatomical marker, and an associated compliance rate of 95% for pre-exposure marker use. If there have been instances of non compliance, these have been actively challenged with the Radiographers involved in order to bring about future quality improvement. North Bristol NHS Trust is also entering a phase of capital replacement with its fleet of X-Ray rooms. We have included an evaluation of safety features as a key part of the clinical trials and procurement. Selection of a suitable system has been made for a new X-Ray room to be installed late 2024. It is predicted that improvements to the X-Ray Imaging equipment will aid Radiographers in making accurate imaging handling decisions and instructions first time. Importantly the flip function that caused concern in this incident w ill have changed its warn ing from a small non-descript icon to a larger FLIP text notification on the X-Ray image. The hardware and software device changes are anticipated to take place across all North Bristol NHS Trust's X-Ray rooms over the next 5 years, offering a service improvement for the patients that receive diagnostic Imaging in these X-Ray rooms. 2) There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients. North Bristol NHS Trust has a standard operating procedure for the communication of critical, urgent and unexpected significant radiological findings . This process includes an instruction to the Radiologist/ Reporting Radiographer who is reporting the images to contact the referring clinician or clinical team by telephone in the event of any critical findings. Any conversation as such is also noted in the formal report. A University of Bristol Teaching Trust. A University of the West of England Teaching Trust. rt!1:b1 North Bristol NHS Trust Following the Regulation 28 Prevention of Future Deaths Report in respect of Mrs Baumgardt, there has been a full review carried out of how we manage a discrepancy in radiographic presentation , and / or side marking. We have already put forward a number of changes to practice, which will now go through our governance sign off prior to them being fully rolled out. These changes are due to be signed off at the Imaging Governance Committee scheduled for 18 June 2024. The changes in practice are listed within a Standard Operation Procedure, and include the following: In the event an anomaly or inconsistency is detected relating to radiographic presentation and/or lateral side marker, then: The Rad iologisU Reporting Radiographer is responsible for: Checking their findings with a senior Radiographer on duty. If inconsistencies cannot be explained and corrected by the RadiologisUReporting Radiographer, then they are to contact the patient's referring clinician by telephone and notify them. Details of any such conversation includ ing the name of the ind ividual spoken with should be noted in the formal report. Conversations must take place with either : a. The referring clinician or clinical team , or b. Senior Radiographer who undertakes a correction of side marking or image orientation to be noted in the formal report By changing to this approach of how we manage any detected inconsistences, this will strengthen an important connection between the production of, and reporting of, images taken by X-ray. This will also present the opportunity to further evaluate the accuracy of the X-Ray image and provide the most accurate and optimum report for the clinical teams involved in the patient's care . It is anticipated that these changes will further improve the quality and accuracy of X-ray image production and reporting. I would like to extend my deepest condolences to Mrs Baumgardt's family for their loss and hope you and they w ill take some assurance from this letter setting out our response in relation to the concerning points you made in your Regulation 28 report. Yours sincerely Chief Executive Enc: New Trust document for undertaking checks during X-ray procedures; A University of Bristol Teaching Trust. A University of the West of England Teaching Trust.
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