Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0344, written 27 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2024 |
|---|---|
| Reference | 2024-0344 |
| Deceased | Paul Holmes |
| Coroner | Stephen Covell |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Road (Highways Safety) related deaths |
| Organisation named | Royal Cornwall Hospitals NHS Trust · Cornwall Partnership NHS Foundation Trust |
| 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.
Chief Medical Officers for CFT and RCHT c/o Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 16th August 2024 Mr Stephen Covell Assistant Coroner for Cornwall and the Isles of Scilly H.M Coroner’s Office Pydar House, Pydar Street Truro, Cornwall TR1 1XU Dear Mr Covell Re: Death of Paul Byron Holmes - R28 PFD Report and letter (ref: 10871060) We write in response to the Regulation 28 Report to Prevent Future Deaths, dated the 13th June 2024 and received on the 27th of June 2024, by both the Cornwall Partnership NHS Foundation Trust (CFT) and the Royal Cornwall Hospitals NHS Trust (RCHT), issued as a result of the inquest into the death of Mr Paul Byron Holmes, which concluded on 22nd of February 2024. We would like to take this opportunity to express our sincerest condolences to the family of Mr Holmes for their loss. During the course of the inquest, the evidence revealed matters giving rise to concern. These are as follows: On Paul's transfer from The Royal Cornwall Hospital to Liskeard Community Hospital on 18 April 2022 1) There was no clear, detailed and direct handover between doctors of the two hospitals. 1 2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals. 3) Any handover which did take place was not properly recorded in Paul's medical notes. 4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed. Please find below a response from the Trusts in relation to each concern you have raised: 1) There was no clear, detailed and direct handover between doctors of the two hospitals. Whilst in the Emergency Department at Treliske, there was a detailed management plan in place for Mr Holmes including the administration of intravenous fluids, oral antibiotics, regular laxatives and restarting his regular diabetic medication. A sputum sample was sent for cultures and a note made to review Mr Holmes’ pain relief. The advice was to continue with ongoing rehabilitation inputs and monitor electrolytes, inflammatory markers and renal parameters. Further to satisfactory improvement, the Consultant who reviewed Mr Holmes on the post- take ward round on the 18th of April 2022, deemed him appropriate to complete his recovery in a community hospital, after stabilising the acute medical illness that Mr Holmes had presented with. The rationale for the transfer was acknowledged as clear at the inquest. There is no documentation of a handover from the discharging Consultant to the accepting team at Liskeard, however this is in-line with expected practice. The expected practice within CFT for admissions to community hospitals would not ordinarily include a doctor-to-doctor handover. Following the decision by the Consultant in RCHT that the patient was appropriate for admission to a community hospital and once a bed was identified, it is expected that a nurse-to-nurse handover would take place. In the case of Mr Holmes, this nurse-to-nurse handover did occur as expected and confirmed that Mr Holmes’ presentation and condition at the point of admission was appropriate to the capacity and remit of the ward. There are some additional safeguards in place for more complex presentations. In the scenario where a patient has needs which cannot safely be met by the nurse-led community hospital, an admission can be refused. There have also been cases, where the patient’s needs are complex, where a doctor-to-doctor handover does take place. Given that there is very limited medical cover available at CFT community hospitals, it is not feasible to change practice to insist on doctor-to-doctor handovers for all admissions to nurse- led wards. 2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals. 2 The handover from the frailty nurse at Treliske was that they did not feel Mr Holmes was septic or had an infection but that he was dehydrated. Intravenous fluids were prescribed. The nursing documentation on the morning of transfer to Liskeard details an update to Mr Holmes’ son, an update on an attempt to administer medication to Mr Holmes and also that a sputum sample and CSU had been sent. There is no documentation of the detail of the handover from the discharging nurse at RCHT. The patient handover form was completed by the receiving nurse at CFT, however, this did not detail the need to continue to treat the patient for dehydration and what to do in the event of a deterioration. Although specific actions in the event of a deterioration were not documented on the handover form, there was a Treatment Escalation Plan (TEP) dated 4th of April 2022 recorded in Mr Holmes’ paper notes, which did detail that Mr Holmes was for escalation back to the acute hospital in the event he deteriorated. The TEP was followed. The response to concern number 3, below, describes that a nurse-to-nurse handover is expected practice and both Trusts propose some actions to strengthen this process. 3) Any handover which did take place was not properly recorded in Paul's medical notes. Within CFT, the verbal nurse-to-nurse handover is documented on a paper record, which is then added to the patient’s paper notes on arrival at the ward. Due to limited communication between the electronic patient records of both Trusts, it is not practicable to produce a shared handover which is apparent on both systems. Both Trusts acknowledge that this poses a risk of there not being a shared understanding about when to escalate the patient for further treatment. Both Trusts propose to review the inter-hospital transfer form used by both the discharging and receiving wards to ensure an escalation plan is documented and to ensure that the handover record in both Trusts is consistent. Any revisions to the handover documentation would need to include a prompt for the discharging and receiving nurse to share any relevant details from the medical management plan. Both Trusts commit to establishing a task and finish group to review the design of the inter- hospital transfer forms and take forward any developments. This group will be established by the start of October 2024. 4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed. It is recognised that there was a delay in administering IV fluids to Mr Holmes as a result of the prescription provided by RCHT having an invalid date. Because CFT and RCHT do not use the same electronic prescribing system, there are inherent challenges when trying to rectify a prescription which is invalid. As detailed in the statements to inquest, efforts were undertaken within CFT to seek a new prescription through the out of hours medical service, which is the only option for medical cover in evenings and weekends. 3 CFT recognise that an additional option in such circumstances would be for the receiving ward to return to the original prescriber to rectify any prescription issues. Upon review with ward managers, this course of action is routinely taken when prescription errors are detected in normal operating hours, however this is not a safeguard which would apply in the out-of- hours scenario which impacted Mr Holmes. RCHT recognise the human error made in the writing of the prescription. The science of human factors (and ergonomics) seeks to understand human interactions with systems of work to identify, prevent and where possible design-out the opportunity for error. In relation to medication incidents, the Trust continually explores how the electronic prescribing system can build-in prompts and highlight where there may be risks to safety such as allergies and drug interactions. We also have processes such as medicine reconciliation which ensure the medicines prescribed to a patient prior to admission are continued. However, errors do sometimes occur for a number of reasons, and we are using education to create a culture of learning, understand error types and ensure the appropriate corrective actions are taken to reduce risk. Whilst training regarding human factors and medication has previously been delivered on an ad hoc basis to all professional groups in the Trust, it is also now part of the revised LEAD programme aimed at all leaders, supervisors, and managers in RCHT. Specific reference to medication errors is made to ensure learning in personal awareness but also that the conditions we create for ourselves (and others) can contribute to slip and lapse errors which can be seen in tasks such as transcription and completing care related tasks. The LEAD programme went live in August 2024 and completion is monitored via electronic staff records. We hope that this letter provides both you and Mr Holmes’ family with assurance that both Trusts have taken seriously the matter of concerns you raised in your report. Yours Sincerely and Chief Medical Officers CFT and RCHT 4
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Cornwall Partnership NHS Foundation Trust 2. Royal Cornwall Hospitals NHS Trust CORONER 1 2 3 I am Stephen Covell one of the Assistant Coroners for Cornwall & the Isles of Scilly 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 14 June 2022 I commenced an investigation into the death of Paul Byron Holmes who died on 29 May 2022 then aged 90. The investigation concluded at the end of the inquest on 22 February 2024. The cause of death was lower respiratory tract infection following a period of terminal decline on a background of delirium, frailty of old age, ketoacidosis, poor oral intake/nutrition, type 2 diabetes mellitus, chronic kidney disease and fractured ribs and sternum. I recorded that Paul Byron Holmes was pronounced deceased at 0645 on 29 May 2022 at Arbour Cottage, Mount Hawke, Truro. Paul died as a result of complications including dementia and a chest infection arising from chest injuries sustained in a road traffic collision on 4 April 2022 and subsequent hospitalisation and loss of mobility against a background of frailty. I recorded a conclusion of road traffic collision. 4 CIRCUMSTANCES OF DEATH i. On 4 April 2022 Paul was a passenger in a vehicle involved in a road traffic collision as a result of which he sustained chest injuries comprising fractured ribs and a fractured sternum ii. Paul was admitted to the emergency department of the Royal Cornwall Hospital Truro the same day for treatment of his injuries. Although Paul was initially lucid, over the subsequent few days he developed delirium which was probably due to a combination of the trauma, his age and frailty, the painkilling medication and disorientation being in a busy acute hospital. iii. On the evening of the 16 April 2022 Paul was transferred from the Royal Cornwall Hospital to Liskeard Community Hospital. Paul's medical condition had stabilised and it was felt that a community hospital was the best location for rehabilitation and for his delirium to settle. The clinician with care of Paul felt that his prognosis was guarded although that was not communicated to Paul's family. iv. Unfortunately Paul's condition deteriorated on 17 April 2022. The nursing staff had difficulty encouraging Paul to eat and hydrate, his heartrate and rate of breathing had increased. Those treating him felt that Paul was suffering from an infection. A decision was taken to transfer Paul back to the Royal Cornwall Hospital which took place in the early hours of 18 April 2022. v. At the Royal Cornwall Hospital Paul was given Intravenous antibiotics and fluids. It was felt that Paul did not have an infection and that the principal issue was dehydration. By late morning on 18 April 2022 clinical staff considered that his condition had stabilised and he could be transferred back to Liskeard albeit that his dehydration had not resolved and intravenous fluids needed to be continued. vi. Because of Paul's ongoing dehydration and overall frailty there needed to be a robust and detailed handover between treating doctors from the two hospitals as to the ongoing treatment plan and what to do in the event of Paul deteriorating. This did not take place. There was a nurse to nurse handover without sufficient details being exchanged or recorded, particularly with regard to the unresolved dehydration. There was also an error in the date of the prescription for the intravenous fluids which resulted in a delay to Paul receiving fluids. vii. Paul's condition deteriorated again resulting in him being transferred back to the Royal Cornwall Hospital at 18.45 the same day where he received appropriate treatment for dehydration and a possible infection. viii. Unfortunately whilst Paul's condition stabilised his delirium persisted and it was felt that he should return home for palliative care. Paul returned home on 16 May where he died on 29 May 2022. ix. The planning and handover for Paul's transfer between the Royal Cornwall Hospital and Liskeard Community Hospital at around midday on 18 April 2022 was inadequate and caused significant discomfort and distress to Paul and a delay to the treatment of the dehydration. It did not however cause or contribute to Paul's death over a month later. 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. On Paul's transfer from The Royal Cornwall Hospital to Liskeard Community Hospital on 18 April 2022 (1) There was no clear, detailed and direct handover between doctors of the two hospitals 5 (2) A treatment plan including the need to continue to treat Paul for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals (3) Any handover which did take place was not properly recorded in Paul's medical notes (4) An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed. 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 22 August 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 8 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. 27 June 2024 9 Signature Stephen Covell Assistant Coroner for
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