Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0397, written 23 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 | 23 Jul 2024 |
|---|---|
| Reference | 2024-0397 |
| Deceased | Janet Rice |
| Coroner | Janine Richards |
| Coroner area | Durham and Darlington |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Executive of County Durham and Darlington NHS Foundation Trust. 1 CORONER I am Janine Richards, assistant coroner, for the coroner area of Durham and Darlington 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. INVESTIGATION and INQUEST On the 22nd of March 2023 an investigation was commenced into the death of Janet Rice. The investigation concluded at the end of the inquest on the 23rd of July 2024 . I gave a narrative conclusion as follows :- Janet Rice, aged 65 years, died at Darlington Memorial Hospital on the 19th of March 2023 as a result of Pulmonary and Cerebral Embolism, subsequent to surgery to repair a hip fracture which she had sustained in an accidental fall on the 19th of February 2023, and in the absence of anti coagulant treatment. The medical cause of death was :- 1a) Pulmonary and Cerebral Embolism 1b) Right sided Neck of Femur Fracture 1 4 CIRCUMSTANCES OF THE DEATH Janet Rice, 65 years, died in hospital on the 19.3.23 as a result of pulmonary and cerebral embolism, subsequent to surgery to repair a hip fracture which she had sustained in an accidental fall on the 19.2.24. In the aftermath of her surgery the deceased did not receive prophylactic anti coagulant medication consistently. On one occasion this was missed due to a transfer between hospitals. On five further occasions this was omitted as a result of the deceased declining such, at a time when she was suffering an acute delirium, and described variously as confused, paranoid and agitated. No assessment of her capacity to decline the medication was carried out, and therefore no best interests decision was made, nor any further consideration given as to how the known high risk of blood clots subsequent to the surgery could be best or alternatively managed. There was no escalation to an Advanced Nurse Practitioner or Doctor to consider these issues further. It is unlikely that the deceased had capacity to decline treatment but impossible to know what the result of any best interests decision would have been, and whether further or alternative actions would have prevented her death. It is accepted that the omission of anti coagulant contributed more than minimally to the development of the Pulmonary Embolism and thus to death. 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 report to you. The MATTERS OF CONCERN are as follows. – (1) The final version of the patient safety investigation report carried out by the Trust was only received on the first day of the Inquest, some 16 months after the death. The concerns raised in this Inquest have been well known to the Trust for a considerable period of time and the concern is that lessons cannot be learned in a timely fashion if patient safety investigations are so significantly delayed. (2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE. (3) Although evidence was heard in relation to the provision of further training in relation to the issues of capacity and best interests decision making, to address the concerns identified in this investigation this was limited to the community hospital setting, when it is known that the issues continued in the acute hospital setting. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17.09.24 . 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; the family of the deceased and the Tees, Esk and Wear Valley Foundation Trust (TEWV). 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 23.07.24 3
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.
Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX E-mail: Our Ref: 13th September 2024 Ms. Janine Richards, Assistant HM Coroner, County Durham Dear Ms Richards, Re: Janet Rice We are writing in response to your request for the Trust to take action in relation to concerns as detailed below: (1) The final version of the patient safety investigation report carried out by the Trust was only received on the first day of the Inquest, some 16 months after the death. The concerns raised in this Inquest have been well known to the Trust for a considerable period of time and the concern is that lessons cannot be learned in a timely fashion if patient safety investigations are so significantly delayed. (2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti-coagulant and does not consider or address the omission to administer anti-coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti-coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti-coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE. (3) Although evidence was heard in relation to the provision of further training in relation to the issues of capacity and best interests decision making, to address the concerns identified in this investigation this was limited to the community hospital setting, when it is known that the issues continued in the acute hospital setting. The Trust would like to offer its sincere condolences to Janet’s family for their loss. We take very seriously the concerns which you have raised and have provided a response below. The final version of the patient safety investigation report carried out by the Trust was only received on the first day of the Inquest, some 16 months after the death. The concerns raised in this Inquest have been well known to the Trust for a considerable period of time and the concern is that lessons cannot be learned in a timely fashion if patient safety investigations are so significantly delayed. The Trust has robust processes in place in relation to the investigation of any patient safety incidents identified. When the Trust were made aware that there were patient safety concerns relating to Janet’s care, in April 2024, a review commenced of her care led by one of the Community matrons. The time taken to conclude and ensure the report had progressed through the appropriate Trust governance resulted in the report not being available to yourself until the morning of the inquest. However we recognise that this was not an acceptable timeframe to enable you to properly review the report. Whilst the progress of patient safety investigations have always been tracked by the corporate patient safety team, additional processes have now been established whereby these cases are tracked at the weekly Friday Senior Clinical Leaders patient safety forum. The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti-coagulant and does not consider or address the omission to administer anti-coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti-coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti-coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE. The Trust acknowledges this and the report has now been reviewed and updated to ensure that all elements of Janet’s care, both acute and community, have been included which is also reflected and incorporated in the action plan (included in Appendix A). Although evidence was heard in relation to the provision of further training in relation to the issues of capacity and best interests decision making, to address the concerns identified in this investigation this was limited to the community hospital setting, when it is known that the issues continued in the acute hospital setting. This is addressed in the action plan included in appendix A. Conclusion We trust that the responses detailed in this letter are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries. Yours sincerely Executive Director of Nursing Executive Medical Director cc. Appendix A: Areas identified that require further action Safety action description Safety action owner (role, team, directorate) Target date for implementation Area for improvement 1: Missed doses of Enoxaparin Plan for monitoring / oversight Review date Improve documentation in the clinical records detailing the reason why a patient has refused medication and escalation steps taken. (Community). Share learning from the case at Quality and Safety huddle for wider learning (Acute site). Pharmacy attendance at Sister’s Away Day to raise awareness of Critical Medications list. (Covers Acute and Community). Area for improvement 2: Carers passports and open visiting (Community). Matron ward manager Starling ward staff. and 31/7/24 Complete Information relayed at handovers/ attend daily huddles. Monitor electronic patient records via monthly audits. 31/8/24 Complete 14/9/24 Complete 30/9/24 Complete 31/7/24 Complete UEC and medicine Care Group Pharmacy Governance Passports ordered. New visiting times and information poster developed and sent for approval. 14/9/24 Complete 30/9/24 Complete 31/8/24 Complete
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