Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0149, written 18 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Mar 2024 |
|---|---|
| Reference | 2024-0149 |
| Deceased | Darnell Smith |
| Coroner | Tanyka Rawden |
| Coroner area | South Yorkshire (West) |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Legal Department The Royal Hallamshire Hospital Broomhill Glossop Rd Sheffield S10 2JF CORONER I am Tanyka Rawden, Senior Coroner for the Coroner area of South Yorkshire West. 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 INVESTIGATION and INQUEST On 7 July 2023 I commenced an investigation into the death of Darnell Errol Hugh Smith, aged 22. The investigation concluded at the end of the inquest on 8 March 2024. The conclusion of the inquest was a narrative conclusion as follows: 1 2 Darnell Errol Hugh Smith was admitted to the haematology ward at the Royal Hallamshire Hospital on 7 November 2022 with a one week history of a reduced appetite, cough and cold like symptoms and no bowel movements for five days. He was admitted to critical care later that day where he was intubated and ventilated. He remained in critical care until he died on 23 November 2022 3 There were missed opportunities between the observations taken on admission to hospital and admission to critical care to take observations on an hourly basis for a minimum of six hours in line with his individualised care plan; to provide intravenous fluids; to monitor for pain; to consider Darnell's health passport and his individualised care plan and to escalate any difficulties in obtaining observations or inserting a cannula. This led to a missed opportunity to identify Darnell's condition was deteriorating but it cannot be said that had an earlier review taken place, his death would have been prevented. CIRCUMSTANCES OF THE DEATH Darnell Errol Hugh Smith had a past medical history which included cerebral palsy, scoliosis, sickle cell disease and epilepsy. He was wheelchair dependent, non-verbal, and he required 2:1 care. 4 Darnell attended the haematology ward at the Royal Hallamshire Hospital at approximately 6pm on 6 November 2022 with a one week history of a reduced appetite, cough and cold like symptoms and no bowel movements for five days. His observations were taken and he was prescribed antibiotics. He returned home. He returned to the Royal Hallamshire Hospital at 1am on 7 November 2022 and was admitted to the the haematology ward. Between his admission at 2.16am and the critical care assessment at approximately twelve hours later, observations were not conducted on an hourly basis for a minimum of six hours in line with his individualised care plan, or every four hours as a minimum as a result or the NEWs 2 score calculated at 2.16am in line with Trust guidelines. Between his admission at 2.16am and the critical care assessment at approximately twelve hours later there were no assessments of Darnell’s pain at thirty minute intervals in line with his individualised care plan. Darnell was not provided with fluids in line with his individualised care plan Darnell’s health passport was not in the records and was not available to staff until approximately 10.50am on 7 November 2022. Darnell’s individualised care plan was in his records but staff were not aware of it. Darnell was admitted to critical care at 4.30pm on 7 November 2022 for sedation and treatment. Darnell responded to treatment initially but by 8am on 8 November 2022 he required additional support to maintain his observations and he was therefore intubated and ventilated. He initially improved from a respiratory perspective but by 16.11.22 he had developed ventilation associated pneumonia By 22 November 2022 he was in type 2 respiratory failure He was extubated and died on 23 November 2022 There were missed opportunities between the observations taken on admission to hospital and admission to critical care to take observations on an hourly basis for a minimum of six hours in line with his individualised care plan; to provide intravenous fluids; to monitor for pain; to consider Darnell's health passport and his individualised care plan and to escalate any difficulties in obtaining observations or inserting a cannula. This led to a missed opportunity to identify Darnell's condition was deteriorating but it cannot be said that had an earlier review taken place, his death would have been prevented. CORONER’S CONCERNS 5 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: The Court heard evidence despite a warning 'flag' being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during his admission. Individualised care plans are crucial to a patient's care and it is my view that without knowledge or sight of them by treating clinicians there is a real risk of further deaths. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 May 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Darnell'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. 18 March 2024 6 7 8 9 Signature Tanyka Rawden H.M Senior Coroner for South Yorkshire West.
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.
Chief Executive’s Office Clocktower Northern General Hospital Herries Road SHEFFIELD S5 7AU 10 May 2024 Ms T Rawden Senior Coroner Office of H.M Coroner The Medico-Legal Centre Watery Street Sheffield S3 7ES Dear Ms Rawden Prevention of Future Deaths Report – Darnell Errol Hugh Smith I write to formally respond to your Prevention of Future Deaths (PFD) Report dated 18 March 2024 following the very sad death of Darnell Smith. I am saddened by Darnell’s death and am very sorry for the distress and upset which this is no doubt causing his parents. Your concern was that despite a warning 'flag' being present on the computerised records identifying the existence of an individualised care plan (ICP) for Darnell, the care plan was hard to locate in the records and was not considered during his admission. We have reviewed current practice and the impact of our new electronic patient record (EPR) system which will be introduced in October 2024. ICPs are agreed with all individuals with sickle cell disease during routine outpatient appointments, and these are filed in the patient record (Lorenzo) with a ‘flag’ which highlights their presence to staff. As you identified, despite this flag, the care plan was not accessed during Darnell’s admission. To address this, we have introduced a number of measures to ensure that staff are aware of ICPs. We will continue to file and flag the ICP in the EPR. We have also started to file a copy of the ICP in the front of the patient’s paper record. In order to ensure that staff always have access to the latest version of the ICP, a new standard operating procedure has been introduced (see enclosure). Once an ICP is agreed, the Haemoglobinopathy (HBO) Clinical Nurse Specialist (CNS) prints off a hard copy of the ICP and places this at the front of the patient’s records to ensure that it is easily accessible. The HBO CNS is responsible for ensuring that whenever an ICP is updated that this is placed in the patient’s record and the old version is removed. Since March 2023, the Matron, Senior Charge Nurse, CNS team and the HBO Consultants hold a daily (7 days a week) board round on each of the Haematology wards. Board rounds take place between 8:45- 9:30am and include a discussion of all new admissions to identify concerns, needs and plans of care. Since August 2023, the HBO CNS attends the MDT board round each morning to discuss any immediate concerns, to agree treatment plans with the attending medical staff, and to provide support and guidance to the nursing teams. PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST For any sickle cell disease patient who has not previously attended the Haemoglobinopathy clinic (e.g. a patient who is new to the area), and therefore does not have an ICP, the HBO Clinical Nurse Specialist ensures that an ICP is written following the Board Round and that this is placed in the patient’s record. In addition, on discharge, there is now a team review of the patient's ICP to identify if any amendments are required based on the most recent admission, for example if changes were made to pain management requirements. This is discussed with the patient prior to discharge by the HBO CNS or the ward senior nurses. Should any changes be required, the CNS team updates the ICP and discusses changes via the HBO MDT. In order to assess the impact of these changes a regular audit has been commenced which includes the availability of an ICP for sickle cell disease patients. The results of this audit will be shared with the Coroner, as requested, by September 2024. All patients with sickle cell disease who are admitted as emergencies are cared for on Haematology wards where the above processes are in place. For planned admissions relating to other primary diagnoses, sickle cell disease patients may be admitted to other wards. On these occasions the HBO CNS team will be made aware of the planned admission and will ensure that the ward staff are aware of the ICP. To support staff caring for sickle cell disease patients an action card has been developed which includes a brief explanation of sickle cell disease, nursing care requirements, reference to STH sickle cell disease guidelines, information regarding ICPs and the pain assessment tool to be used when caring for sickle cell disease patients (see enclosure). In addition, there is a focus on ICPs within the sickle cell disease educational package. Since commencing this programme of work, 50 Haematology nursing staff have attended training sessions, with a further 33 planned to receive training by July 2024. Education has also been delivered to staff in the Emergency Department to ensure that they are also aware of ICPs, should a patient present to them rather than coming directly to the Haematology department. As part of the preparation for launching our new Connect EPR we have considered how ICPs will be recorded and flagged in the new system. Whilst this is subject to final configuration and testing, it is planned that: • The ICP will be recorded directly into the documents section of the EPR. • When any clinical member of staff opens the patient's record, an alert will show on a pop-out telling them that the patient has an ICP. • The alert will provide the user with a link to the plan. Having outlined the actions we are taking in response to your report, I hope that I have been able to convey how seriously we have taken this matter. We are absolutely committed to learning from Darnell’s death and implementing these actions. Finally, I hope that my response has addressed the concerns and actions you identified in your Report. Please contact me if you have any queries or points of clarification. Yours sincerely Chief Executive Enclosures: 1 – SOP for Individualised Care Plans for Patients with Sickle Cell Disease 2 – Sickle Cell Disease Action Card PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST
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