Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0382, written 17 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 | 17 Jul 2024 |
|---|---|
| Reference | 2024-0382 |
| Deceased | Pauline Spedding |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care: The Department of Health and Social Care 1 CORONER I am JACQUELINE LAKE, Senior Coroner for the coroner area of Norfolk 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. 3 INVESTIGATION and INQUEST On 28 March 2023 I commenced an investigation into the death of Pauline SPEDDING aged 69. The investigation concluded at the end of the inquest on 08 July 2024. The medical cause of death was: 1a) 1b) 1c) 2) Acute Left Subdural Haematoma Fall Type 2 Diabetes Mellitus, Postural Hypotension, Chronic Kidney Disease, Aortic Stenosis, Frailty, Extended-Spectrum Beta-Lactamase Escherichia Coli Urinary Tract Infection The conclusion of the inquest was: Accident 4 CIRCUMSTANCES OF THE DEATH Mrs Spedding had a complex medical history and a history of falls and was frequently admitted to hospital as a result. Mrs Spedding was admitted to Norfolk and Norwich University Hospital from 11 to 15 February 2023 and again from 18 February to 6 March 2023 due to falls. On 7 March 2023 Mrs Spedding had a further fall at home and was admitted to Norfolk and Norwich University Hospital. There were deemed to be multifactorial reasons for her falls and she was identified as at high risk of falls. Consideration was being given to discharging Mrs Spedding when she had an unwitnessed fall in the bathroom on 13 March 2023. She was examined and no concerns were raised regarding injury. On 17 March 2023 Mrs Spedding was found lying on the floor by the sink in the bay. She was examined and no significant injury was found. On 18 March 2023 Mrs Spedding was moved to Gunthorpe Home First Unit which cares for patients medically fit for discharge and awaiting input into care needs. It aims to encourage independence and encourages movement. On 20 March 2023 Mrs Spedding was positive for Escherichia coli and she was moved to a side room. The risk of infection was not documented alongside her high risk of falls. The Falls Response Team was not notified. On 24 March 2023 at 00.20 Mrs Spedding was found on the floor next to her bed and had a graze to her elbow. Regulation 28 – After Inquest Document Template Updated 30/07/2021 At 03.30 hours Mrs Spedding was found sitting on the floor next to her bed. She declined observations. Mrs Spedding was reviewed by a doctor at 04.55 and a CT scan was requested Mrs Spedding became increasingly unresponsive and she suffered a pericardiac arrest. The CT scan showed a large subdural haematoma. Mrs Spedding’s condition continued to deteriorate, and she died later that morning. Throughout her stay falls risk assessment documentation, care plan documentation and hot debrief documents were not completed or not completed in full. Mrs Spedding was not referred to the Falls Response Team. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: 1. Consideration was being given to discharging Mrs Spedding from hospital from on or about 13 March 2023 and steps were being taken to find a suitable placement for her. 2. Mrs Spedding was moved between five wards during her inpatient stay between 7 March 2023 and her death on 24 March 2023, resulting in breaks in the continuity of care for Mrs Spedding and the requirement for more risk assessments to be carried out and documentation to be completed by staff. 3. The reason for the number of moves between wards was given as being due to excess beds being required in hospital over and above those which would usually be expected, as a result of difficulties with the number of patients being admitted and those able to be discharged. 4. Evidence was heard that corridors are being used to accommodate patients and seven beds are being placed in wards intended for six beds. These additional beds are referred to as “escalation beds”. 5. Evidence was heard that in 2023 there were 44 escalation beds in use and for June 2024 there were 66 escalation beds in use. During the winter of 2023/2024 the number of escalation beds rose to 120. The Falls Prevention and Management Lead for the hospital referred to the elderly population in Norfolk and life expectancy being lower with resultant health issues in many parts of the county and felt it unlikely that the hospital would not need escalation beds in the foreseeable future. 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 September 11, 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 the following Interested Persons: Regulation 28 – After Inquest Document Template Updated 30/07/2021 Norfolk and Norwich University Hospital, Legal Department, I have also sent it to: Department of Health Care Quality Commission HSIB Healthwatch NHS England (NHS Improvement) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 17/07/2024 Jacqueline LAKE Senior Coroner for Norfolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 9th October 2024 Our ref: HM Coroner Jacqueline Lake Norfolk Coroner’s Service County Hall, Martineau Lane Norwich NR1 2DH By email: Dear Ms Lake, Thank you for the Regulation 28 report of 17th July 2024 sent to the Secretary of State about the death of Pauline Spedding. I am replying as Minister with responsibility for urgent and emergency care. Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Spedding’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report. The report raises concerns over the continuity of care for Mrs Spedding, who had a complex medical history, and bed capacity issues at Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH). In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. Your report raised concerns regarding the continuity of care provided in this case following the movement between wards as a result of bed capacity pressures. I am informed that NNUH has undertaken focused work on this issue which has reduced the number of moves for patients during their inpatient stay. Patients are assessed prior to moving and moves are only undertaken if the clinical priority of another patient requiring that bed space is higher. The number of moves per patient is monitored and reviewed weekly to confirm if they were appropriate or to identify improvements to reduce the number of moves. A nursing assessment booklet has been fully implemented across the trust and the trust’s audits show that there have been improvements. In relation to escalation bed processes, I am also advised that the trust has reviewed and strengthened processes for the use of escalation beds and the plans for de-escalation, which has reduced the number of escalation beds used since July to date. NNUH will continue to review internal processes to minimise risk to patients. The trust will continue to work with stakeholders and partner providers across the system to reduce the need for escalation beds. In relation to delays to patient discharge, it is vital that people are discharged safely from hospital when they are medically ready. Enabling people to be discharged from hospital more quickly with the right care and support in place contributes to speedier recovery and better outcomes for patients. NNUH has advised that finding suitable placements for patients unable to return to their own homes remains a priority as part of their transfer of care. Those with a length of stay of over 21 days are reviewed weekly by appropriate nursing teams. At a national level, this government is committed to supporting the NHS to recover back to the level of service patients rightly should expect. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.