Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0266, written 14 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 May 2024 |
|---|---|
| Reference | 2024-0266 |
| Deceased | James Pearson |
| Coroner | Rebecca Ollivere |
| Coroner area | Birmingham and Solihull |
| Category | Road (Highways Safety) related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
10 July 2024
FAO Assistant Coroner Rebecca Ollivere for Birmingham and Solihull
By way of email only:
Dear Ms Ollivere
Inquest touching the death of James Patrick Pearson
Response to Regulation 28 Report to prevent future deaths.
I am writing in response to the Regulation 28 notice issued following the conclusion of the
inquest on 2 May 2024, into the death of Mr Pearson on 22 October 2023 at St Catherine’s
Hospice, Preston.
We have carefully considered the concerns raised within your report to prevent future deaths
and our response is set out below.
Unfortunately, the report presented at inquest mistakenly stated the unit was a Major Trauma
Centre, which it is not and should have advised it is a Trauma Unit. I would like to apologise
for this error in terminology and assure you the report has been revised to clarify this point.
Lack of documented observations
During the Inquest you heard evidence that whilst Mr Pearson was attached to a monitor which
was taking his observations every 15 minutes, these were not being documented and you are
concerned that the lack of documented observations could result in a failure in identifying a
deteriorating patient.
The Trust adheres to RCEM standards for observations, which are as follows:
“STANDARD 1: Patients triaged to the majors or resuscitation areas of the ED should have
the following measured and recorded in the notes within 15 minutes of arrival or triage,
whichever is the earliest:
respiratory rate
•
• oxygen saturation
• pulse
• blood pressure.
• GCS or AVPU score
•
temperature
STANDARD 2: Patients with abnormal vital signs should have their vital signs repeated and
recorded in the notes every 60 mins from first set of observations.
STANDARD 3: There should be explicit evidence in the ED record that the clinician recognised
the abnormal vital signs (if present).
STANDARD 4: There should be documented evidence that the abnormal vital signs (if
present) were acted upon in all cases”.
Whilst observations are not documented every 15 minutes, they are monitored and any trigger
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Following an alert, there are periods of time when a patient may be undergoing imaging
outside of the Emergency Department; these observations will still be monitored but not
recorded via PICS, which is relevant to this case.
During an alert when there is ongoing dynamic assessment and resuscitation, staff are not
expected to document contemporaneously but do document an account of observations and
actions taken as per RCEM and Trust standards. It should be noted that PICS does not permit
the retrospective entry of observations on the chart.
The standards set out above and expected documentation has been reiterated at Emergency
Department huddles to ensure that recording within noting is robust and will be audited as part
of the action plan following this Serious Incident Investigation t provide assurance that these
standards are being adhered to.
Medical resourcing of the Trauma Unit/ED
We regularly review our workforce numbers in conjunction with best practice guidance and
benchmarking. We have participated in the RCEM England census to benchmark our doctors’
numbers, we have also utilised NHSE tools to review our rota patterns against attendance
numbers with the aim of achieving resilience to the 75th centile of attendances.
We have reviewed the rotas for both 13 June 2023 and 14 June 2023.
Mr Pearson arrived in ED in the period covered by the night shift rota for 13 June 2023. We
use RCEM recommendations on tiers to produce our standardised rota patterns for Heartlands
Hospital, which as stated above is a Trauma Unit.
Our standard ED night staffing at BHH is for:
• For an ED (non-MTC) with >100,000 attendances a year, one consultant overnight on
call, and one senior decision-maker (does not have to be a consultant) in the EPIC role
is recommended for a night shift (RCEM 2019).
• 1 tier 4 doctor (highlighted in orange on the rota as a standard clear indicator of doctor
in charge)
• 3 additional tier 3 or tier 4 doctors.
• 4 Tier 2 doctors
• 1 Emergency nurse practitioner (ENP) for minor injury only
On the night in question, we have observed that the minimum staffing was met, with an
additional tier 2 doctor and an additional ENP.
To ensure we continue to meet minimum staffing levels in the ED there is a twice weekly
forward look meeting with the rota team to confirm minimum numbers are met, and to be
aware of where there are dips in cover and these undergo a process of escalation via the ED
general manager in order to consider all mitigation options including agency use, locum,
support from other specialty teams at middle grade level as examples.
The rota team consists of the following:
• 1 ED rota manager lead
• 3 additional ED rota team admin support assistants
• 1 consultant lead for Junior Doctors’ rota
Whilst we are satisfied that our current model provides resilient staffing to the mean
attendance profile and that our processes enable resilience of staffing with clear escalations
where minimum staffing is predicted to not be achieved, we are currently reviewing the
demand and capacity for the unit. This is to ensure our staffing is modelled correctly to ensure
the baseline for the substantive workforce is correct. Although we meet RCEM criteria in
terms of staffing on duty, to meet this we utilise a number of bank staff. The demand and
capacity modelling will ensure the unit has identified what the substantive workforce should
look like, to provide additional resilience. This work will be completed by August 2024.
Availability of blood products within the emergency department
You heard evidence that it can take up to 20 minutes to obtain blood products within the
emergency department following activation of the major haemorrhage protocol. Whilst this
delay was unlikely to have affected the outcome for Mr Pearson, you are concerned that
delays in blood products being available could result in future deaths.
The recommendation to consider a blood fridge in BHH ED has been discussed in the Hospital
Transfusion team. There are significant consequences to putting a fridge in the ED at BHH,
not least that group O blood (which is what would need to be in the fridge if it is being used to
support immediate transfusion) is in short supply nationally and needs to be used only for
those patients that require it. This includes not stocking it in locations where it is unlikely to be
used, which includes EDs (such as Heartlands) which are not in Major Trauma Centres.
Whilst the report to the coroner identifies that the delay was in requesting blood/activating the
Major Haemorrhage Protocol (MHP), once this was done the blood arrived quickly. The blood
arrived within 15 minutes which is the time stipulated by our Trust procedures and recognised
to be acceptable against national norms.
A review of all incidents involving activation of the MHP within Heartlands Emergency
Department since Mr Pearson’s death has been undertaken. This did not demonstrate any
incidents regarding delays in receipt of blood once the MHP was activated. A full audit is
underway by the Hospital Transfusion Group to review overall compliance to the Major
Haemorrhage Blood Protocol across all UHB sites, the outcome of this will be reported to the
Trust Transfusion Committee.
I would like to assure you that the concerns raised within the Regulation 28 Report have been
taken extremely seriously, which I hope is demonstrated in the steps that have been taken
following Mr Pearson’s death.
Yours sincerely
Chief Executive
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: University Hospitals Birmingham NHS Foundation Trust CORONER I am Rebecca Ollivere, Assistant Coroner, for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 9 November 2023 I commenced an investigation into the death of James Patrick PEARSON. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Died as a result of complications of prolonged hospital admission, in combination with injuries sustained in a road traffic collision, and subsequent hypoxic brain injury, following cardiac arrest. 1 2 3 CIRCUMSTANCES OF THE DEATH On 14th June 2023, James Pearson was hit by a vehicle on A4540 Birmingham. He was assessed at the scene and his injuries did not appear to be serious. He was taken to Birmingham Heartlands Hospital where a CT scan showed an axonal brain injury, small bleed to the brain, and severe pelvic injuries with suspicion of an active bleed. Observations taken at 03.16 indicated that he was maintaining his blood pressure and the Consultant at the time did not feel he was actively bleeding. James went into peri-arrest, and subsequently suffered a cardiac arrest. After 12 minutes of CPR, a return of spontaneous circulation was achieved, however, James had suffered hypoxic brain injury as a result of the cardiac arrest. This, alongside the traumatic brain injury sustained in the road traffic collision resulted in a prolonged stay in hospital for James, who continued to decline, and developed hospital acquired pneumonia. He was transferred to St Catherine's Hospice in Preston on 12th October 2023 for end of life care, and he passed away there on 22nd October 2023. Whilst at Birmingham Heartlands Hospital an opportunity to provide fluids to James was missed, which, on the balance of probabilities would have prevented his cardiac arrest and subsequent hypoxic brain injury. Following a post mortem, the medical cause of death was determined to be: 4 1a Pneumonia 1b Diffuse axonal injury and hypoxic brain injury 1c Road traffic collision II Malnutrition 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. Having had a CT scan at Birmingham Heartlands Hospital on 14th June 2023, James Pearson was diagnosed with severe pelvic injuries, and the Radiologist reported findings which were consistent with an active pelvic bleed. 2. At 03.16, observations were taken, and the Doctor was satisfied that James was maintaining his blood pressure and therefore was not actively bleeding at that time. 3. During the inquest, I heard that James was attached to a monitor, which was taking his observations every 15 minutes. None of these observations, however, were documented. This is of concern, as it is not possible to know at what point James began to decline. I am concerned that lack of proper documented observations could lead to future deaths, as staff will not be able to follow the observation pattern and notice a decline in presentation. 4. At 04.20am, James became more agitated and nurses noted a drop in consciousness. At this point the Major Haemorrhage Protocol was activated at 04.23am, as there was now a suspicion of ongoing bleeding. 5. Whilst waiting for his blood products, James suffered a cardiac arrest at 04.25am 6. told me in evidence that during the time since his last review by a Doctor at 03.16am, and his cardiac arrest at 04.25am, James was not seen by a Doctor, and only Nurses were available in the department. The only Doctor on shift at that time was dealing with another very unwell patient, who also required resuscitation. 7. told me that at the point in time the deterioration in James was noted, sometime between 04.00-04.20am, James should have received fluids, and in his opinion, if he had done so, on the balance of probabilities, he would not have had a cardiac arrest. He added that this was beyond what he would expect a nurse to adduce, however, if the Doctor had been present, he believed this would have been done. 8. I am therefore concerned that there were not enough Doctors in the department at the time, meaning that there is no resilience to deal effectively with more than one very unwell patient at any given time. If this is not addressed, there is a risk of future deaths. 9. I further heard from that the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for James, due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have 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 9th July 2024. I, the coroner, may extend the period. 7 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:- , James’ mother I have also sent it to the Medical Examiner, ICS, NHS England, CQC, who may find it useful or of 8 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. 14 May 2024 9 Signature: Rebecca Ollivere Assistant Coroner for Birmingham and Solihull
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