Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0403, written 25 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 | 25 Jul 2024 |
|---|---|
| Reference | 2024-0403 |
| Deceased | Elizabeth Holder |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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.
MR G IRVINE SENIOR CORONER EAST LONDON Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: 26837383 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Trust Sent via email: Care Sent via email: , Chief Executive Officer, Barts Health NHS Foundation , Secretary of State for Dept. Health & Social 1 CORONER I am Graeme Irvine, senior coroner, for the coroner area of East London 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 On 1st March 2024 this Court commenced an investigation into the death of Elizabeth Grace Holder, aged 88 years. The investigation concluded at the end of the inquest on 24th July 2024 when the Court returned a narrative conclusion: “Elizabeth Grace Holder died in hospital on 24th February 2024 due to complications of 1 a fall that occurred whilst recovering from surgery as an inpatient. At the time of the fall, Mrs Holder was not properly supervised.” Mrs Holder’s medical cause of death was determined as; 1a Intraparenchymal haematoma 1b Fall II Neck of femur fracture (corrected), intraparenchymal haemorrhage 4 CIRCUMSTANCES OF THE DEATH Elizabeth Grace Holder was an 88-year-old woman with co-morbidities, restricted mobility and a history of falls. Elizabeth was admitted to hospital on 29th December 2023 by ambulance following a fall, she was admitted to the trauma unit and underwent a surgical repair of a broken hip. Mrs Holder was noted to be at high risk of falls and had been assessed to require an enhanced level of nursing care, initially requiring 1:1 nursing care. Mrs Holder had a difficult recovery and developed a surgical wound infection. During her inpatient recovery period the patient lost physical reserve and was observed to be increasingly confused, despite this nursing care was reduced to a 1:2 ratio. On 15th February 2024 it was noted that Mrs Holder had declined further, she was markedly confused and underwent diagnostic tests resulting in a queried diagnosis of a transient ischaemic accident. On the evening of 19th February 2024 Elizabeth was observed to be confused and anxious. Mrs Holder had asked to be taken to the lavatory, her request was refused, and she was told to use the commode by a male Health Care Assistant (“HCA”). The HCA did not believe that it was appropriate for him to observe Mrs Holder in the use of the commode and allowed her to proceed unsupervised behind a ward bay curtain. The HCA did not consider alternative, safer strategies, neither asking the female nurse allocated to Mrs Holder on the same shift to undertake supervision, nor offering to supervise use of the commode in the presence of a chaperone. The fall resulted in a fatal intra-cerebral bleed. CORONER’S CONCERNS 5 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 Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death. 2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any sub- optimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to; Identify and reflect upon failings in care, a. b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s death. 6 ACTION SHOULD BE TAKEN 2 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th September 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 the family of Mrs Holder, the Care Quality Commission and to the local Director of Public Health 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 other 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. 9 [DATE] 25/07/2024 [SIGNED BY CORONER] 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.
Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 13 September 2024 Our ref: HM Coroner Graeme Irvine The Coroner's Court Queen's Road Walthamstow E17 8QP By email: Dear Mr Irvine, Thank you for the Regulation 28 report of 25 July sent to the Department of Health and Social Care about the death of Mrs Elizabeth Grace Holder. I am replying as the Minister with responsibility for Patient Safety. Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Holder’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the Barts Health NHS Foundation Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death. Despite this incident activating the Patient Safety Incident Response Framework (PSIRF) at the Trust, no sub- optimal aspects to Mrs Holder’s care were identified. Thus, there are concerns around the failure of the Trust’s governance systems to: Identify and reflect upon failings in care, a. b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s death. In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure we adequately address your concerns. The Barts Health NHS Foundation Trust is also a direct recipient of this report as the concerns raised relate to the failures at the Trust. I have received assurance that they will be providing a response to address your concerns. I welcome this, so we can better understand what went wrong and deaths such as Mrs Taylor’s can be prevented in the future. A key concern in your report is around the investigation conducted by the Trust and its governance processes. As you might be aware, the PSIRF became a contractual obligation for all Trusts from 1 April 2024, replacing the Serious Incident Framework (SIF). Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU PSIRF overhauls the way Trusts respond to patient safety incidents with a focus on more effective learning and engaging families. Under the SIF, hospitals were only required to investigate incidents that reached the threshold for being defined as ‘serious’. This sometimes meant that other incidents were not investigated or learned from. For patients and families, the former process could be long and drawn out, and some patients reported feeling shut out from investigations. PSIRF aims to provide a more flexible, transparent and compassionate approach to learning responses and investigations, focused on understanding the different factors that contributed to incidents and ensuring organisations learn from them. I have been informed that the CQC will be discussing the PSIRF in upcoming meetings with the Trust. The CQC also continue to monitor the Trust and will consider whether further action is appropriate or necessary. I look forward to any developments which could provide a deeper understanding of the underlying issues at the Trust and help preventing future deaths such as Mrs Holder’s. I strongly believe that working with the NHS to deliver learning from patient safety errors is crucial to changing the way patient safety is approached in the NHS. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
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