Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0372, written 12 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jul 2024 |
|---|---|
| Reference | 2024-0372 |
| Deceased | Sandra Phillpott |
| Coroner | Alan Anthony Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals 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 THIS REPORT IS BEING SENT TO: Chief Executive, Blackpool Teaching Hospitals NHS Foundation Trust 1 CORONER I am Alan Anthony Wilson Senior Coroner for Blackpool & Fylde 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 The death of Sandra Phillpott on 31st October 2023 was reported to me and I opened an investigation, which concluded by way of an inquest on 5th July 2024. I determined that the medical cause of Sandra’s death was: 1a Multi - organ failure 1b Sepsis with Disseminated Vascular Coagulation [D.I.C] 1c Streptococcus Pneumoniae II E.coli 0157 infection; left ventricular hypertrophy; coronary artery atheroma In box 3 of the Record of Inquest I recorded as follows: Sandra Phillpott was aged 57 years. She was regarded as active and previously healthy. At around 5pm on Friday, 27th October 2023 she returned home after a holiday in Egypt with her twin Sister. By the time she arrived home she was experiencing some cold-like symptoms due to a bacterial infection - later identified as E.coli 0157 - contracted whilst in Egypt from an unidentified source. The situation was complicated after she then developed a pneumococcal infection which left her feeling cold and shivering. Over the course of that weekend, Sandra remained unwell but did not deteriorate noticeably until the morning of Monday 30th October 2023. She had largely preferred not to seek medical attention, expecting her symptoms to improve. After her condition became more concerning she attended a walk - in - centre from where she was appropriately transferred to the hospital emergency department. She had to remain in an ambulance for around forty minutes before she could enter the department. Initial investigations suggested she had a suspected pulmonary embolism, but she was also showing signs of infection and by 12 noon antibiotics and intravenous fluids had been prescribed. These were not administered in a timely fashion. Her presentation had not indicated she had a specific pneumococcal infection until later that afternoon when following a delayed transfer to the intensive treatment unit a consultant noted a florid rash indicative of pneumococcal sepsis. The results of blood tests would later confirm the infection to be Streptoccocus Pneumonaie. Over subsequent hours, Sandra's condition deteriorated and her death confirmed at 05.50 hours on 31st October 2023. The likelihood Sandra had sepsis had been under appreciated, and there was a missed opportunity to provide timely antibiotic therapy and fluids, but from the available evidence this would not have altered the fatal outcome because from around the time antibiotics were prescribed, Sandra's condition was non - survivable. She died from complications arising from a pneumococcal infection. She had been more susceptible to dying from such infection due to the effects of heart disease identified at post mortem examination, and reduced physiological reserves caused by the separate infection which had been contracted in Egypt. In box 4 of the Record of Inquest I determined that: Natural causes. 4 CIRCUMSTANCES OF THE DEATH In addition to the contents of section 3 above, the following is of note: As mentioned above, despite showing signs of infection, the necessary treatment was not provided in a timely manner, notably antibiotic therapy and the administration of intravenous fluids. Sandra’s shortness of breath, some reported calf pain, and recent flights contributed to a feeling amongst some of the clinical / nursing staff that she had a likely pulmonary embolism [later ruled out] and this in part contributed to a lack of focus on the possibility she had developed a potentially fatal infection. A helpful Patient Safety Incident Investigation [PSII] Report, provided to the court in advance of the inquest by Blackpool Teaching Hospitals NHS Foundation Trust, found that: There had been delays in sepsis management The initial treatment had focused upon ruling out a pulmonary embolism and deep vein thrombosis, delaying sepsis management. Sandra had multiple sepsis triggers, but the main focus remain a pulmonary embolism. Having considered all of the above, I have determined that I have a duty to write this report. 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 could occur unless action is taken. In the circumstances it is my statutory duty to send the report: The MATTER OF CONCERN is as follows. – The concern I raise relates to the recognition of suspected sepsis, and the need for timely provision of treatment for suspected sepsis. Notwithstanding that I determined that from the available evidence timely treatment would not have altered the fatal outcome, I remain firmly of the view this report is necessary. I was informed at the inquest that there have been significant improvements in the management of sepsis within the Emergency Department. This court has raised concerns with the hospital Trust about this issue previously, and I know it is an issue which the Trust is very aware of and I do not doubt that efforts have been made to make improvements, but having conducted this inquest into Sandra’s death, in my view there remains a risk that sepsis will go unrecognized, and urgent treatment will be delayed, putting patients attending Blackpool Victoria Hospital at risk. My duty to write this report is therefore met. It is not for me to be prescriptive about what action ought to be taken, but to raise this concern should I feel this is necessary. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. Given the approaching holiday period I have extended this period to Friday 13th September 2024. I, the coroner, may extend the period further. 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: The family of Sandra Phillpott. 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 12/07/24 _____________ Signature_____ Alan Anthony Wilson Senior Coroner Blackpool & Fylde
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.
Trust Headquarters
Blackpool Victoria Hospital
Whinney Heys Road
Blackpool
FY3 8NR
Telephone:
Email:
12th September 2024
FAO Mr Alan Wilson
Coroner for Blackpool and Fylde
PO Box 1066
Corporation Street
Blackpool
Lancs, FY1 1GB
Via email:
Dear Mr Wilson
Re: Regulation 28: Report to Prevent Future Deaths – Sandra Philpott
Firstly, on behalf of Blackpool Teaching Hospitals NHS Foundation Trust, I should like to offer my sincere
condolences to the family of Ms Philpott.
Thank you for raising your concerns regarding sepsis with the Trust, please find below the Trust responses
to the issues raised in the report to prevent future deaths.
Concerns Raised
• The concern I raise relates to the recognition of suspected sepsis, and the need for timely
provision of treatment for suspected sepsis.
• Notwithstanding that I determined that from the available evidence timely treatment would not
•
have altered the fatal outcome, I remain firmly of the view this report is necessary.
I was informed at the inquest that there have been significant improvements in the management
of sepsis within the Emergency Department.
• This court has raised concerns with the hospital Trust about this issue previously, and I know
it is an issue which the Trust is very aware of and I do not doubt that efforts have been made
to make improvements, but having conducted this inquest into Sandra’s death, in my view
there remains a risk that sepsis will go unrecognized, and urgent treatment will be delayed,
putting patients attending Blackpool Victoria Hospital at risk. My duty to write this report is
therefore met. It is not for me to be prescriptive about what action ought to be taken, but to
raise this concern should I feel this is necessary.
Chairman:
Chief Executive:
RESEARCH MATTERS AND SAVES LIVES – TODAY’S RESEARCH IS TOMORROW’S CARE
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality
up to date care. We are actively involved in undertaking research to improve treatment of our patients.
A member of the healthcare team may discuss current clinical trials with you.
Trust response
For context, I provide detail regarding the Trust’s improvement journey relating to the recognition and
management of sepsis, and the ongoing actions which remain in focus to ensure the safety of our patients.
In April 2022 following an unannounced inspection at Blackpool Teaching Hospital (BTH), the Care Quality
Commission (CQC) issued a Regulation enforcement action Section 31, under the Health and Social Care
Act 2008. The CQC deemed that there was a lack of quality assurance in relation to the care and treatment
of patients with suspected or confirmed sepsis. In response, the organisation committed to an improvement
programme, with the following key areas of focus:
• To overcome barriers surrounding underperformance within the sepsis pathway,
• To improve the care of patients with suspected or confirmed sepsis,
• To ensure that the Trust had robust governance arrangements in place to demonstrate compliance
and alert any concerns.
Once these areas of focus had been addressed it was expected that this would support an application for
the CQC Section 31 notice and associated licence conditions to be lifted and improvements transacted into
business as usual processes, where they would be monitored and sustained.
Two sepsis leads were nominated for the organisation and put into place. The Associate Medical Director,
and the Associate Director of Nursing/Harm Free Care led the response, ensuring system wide action,
governance, and oversight.
To support staff knowledge, briefings for all staff were developed and shared through safety huddles, team
meetings and training. This was supported by ward/ unit level ‘teach/learn’ audits whereby the ward
managers/ leaders ask staff questions related to sepsis each month and use the results to improve practice.
For sustainability sepsis was included in the mandated recognise and act training for all clinical staff and
inductions.
A new sepsis proforma was developed for clinical practice and the policy updated. Historically, the Trust
had contributed to the AQUA audit for peer review and had a composite process score of around 30% and
ranked below 12th position in the league tables within our area. The AQUA audit is of a small percentage
of patients each quarter. This process was improved by increasing the number of audits to 40 patients per
week, through the clinical audit team, with validation being completed weekly by the Associate Directors.
This more detailed audit provided the team with richer data which enabled the identification of learning
themes and areas of targeted focus. The learning themes were used to design a quality improvement
collaborative which began in May 22 for the management of patients with sepsis. A change package was
developed and initially 10 teams from across the trust took place in the collaborative to improve the
management of patients. This work was then shared across the organisation through the clinical teams.
At the time of Ms Philpott’s sad death, the Trust’s AQUA pathway compliance performance was on an
improving trajectory, which has been sustained for over 6 months with the Trust’s current compliance
reported at 90% against the Composite Process Score (CPS).
For areas with high numbers of sepsis patients, such as the Emergency Department (ED), a weekly review
meeting was put in place and has continued to ensure focus on data and improvements. Overall
compliance to the actions from the organisation are reviewed through a monthly subject matter expert group
for sepsis, where the data, training, new ways of working are monitored.
Current position
The Trust has in place an updated sepsis policy, which includes the sepsis six, and is in line with national
guidance and requirements. The Trust has identified sepsis leads and a comprehensive sepsis training
package. The Trust has in place a Sepsis Quality Improvement (QI) Collaborative to support the work
being undertaken regarding sepsis and to drive improvement. The Trust also undertakes monthly audits
of sepsis performance and has demonstrated significant improvement across the sepsis six.
2
For transparency and oversight sepsis compliance is reported to the wider organisation through both
Clinical Governance Committee and Quality Assurance Committee. Divisions include sepsis pathway
compliance, training data and clinical concerns in divisional governance meetings. For sustainability,
the sepsis CPS score is now included in the organisational integrated performance report which is overseen
at the Quality Assurance Committee and is reviewed at the Trust’s performance forum, the Performance,
Improvement, Delivery and Assurance (PIDA) Meeting and at Trust Board to ensure continuing compliance
with the pathway.
Across the region the AQUA data reflects the improvements and work undertaken, with the Trust ranking
5th regionally, out of 15, for sepsis compliance and performance. The Associate Directors have also
contributed to the regional AQUA expert sepsis group to improve standards. Mersey Internal Audit Agency
(MIAA) were requested to ‘test’ the Trust’s evidence of improvement to support the application for the
removal of the Trust’s Section 31 licence conditions. The review returned an opinion of high assurance.
The application for the removal of the Trust’s Section 31 licence conditions was submitted in May 2024.
The CQC reviewed the evidence and improvement data submitted and informed the Trust in July 2024 that
the licence conditions had been removed.
The Trust continues to keep sepsis in focus with monthly updates provided to the Trust’s Clinical
Governance Committee, and Quality Assurance Committee regarding sepsis pathway compliance.
The current area of focus for improvement are:
- Time to recognition for suspicion and diagnosis of sepsis to initiate time critical pathway
- Early Escalation of The Acutely Unwell Patient.
In the next 12 months, The Quality Improvement team are focusing on all Escalation Pathway work with
expert forums and trust wide events.
I would like to assure you that if our records show that a patient’s sepsis has not been identified within the
appropriate timescale, incidents are submitted on the Trust’s incident management system. Where harm
is suspected the Trust undertakes a Rapid Review which is presented to the twice weekly Rapid Review
Panel. This process ensures that appropriate learning is identified and a proportionate learning response
deployed. Where learning is identified, this is fed into the Trust’s sepsis pathway group to enable further
improvements to be initiated.
I hope that my response has provided you with the assurance you require that the Trust continues to place
significant improvement focus on the identification and management of sepsis with well embedded systems
for oversight and improvement where harm is identified. Should you require any further information or
evidence, this can be provided.
Yours sincerely
Chief Executive
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