Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0410, written 29 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 | 29 Jul 2024 |
|---|---|
| Reference | 2024-0410 |
| Deceased | Wendy Hammon |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Wendy HAMMON A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Interim Chief Executive Ashford and St. Peter’s Hospitals NHS Foundation Trust 2 CORONER Miss Anna Crawford, H.M. Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST An inquest into Mrs Hammon’s death was opened on 27 October 2022. The inquest was resumed on 24-25 June 2024 and concluded on 12 July 2024. The medical cause of Mrs Hammon’s death was: 1a. Multi-Organ Failure 1b. Non-Occlusive Mesenteric Ischaemia 1c. Small Bowel Obstruction due to Adhesions from Previous Surgery (2011) 2. Chronic Kidney Disease The inquest concluded with a narrative conclusion as follows: Mrs Hammon had a past medical history which included chronic kidney disease. In 2011 she had developed ischaemic bowel, due to Streptococci A, and had undergone surgery to remove a portion of her bowel and to create an ileostomy. As a result of the procedure in 2011 she developed scar tissue known as adhesions, which are a recognised complication of the procedure. On 30 August 2022 Mrs Hammon was admitted to St. Peter’s Hospital with abdominal pain, vomiting and a non-functioning stoma. She was diagnosed with, and treated non-operatively for, a small bowel obstruction caused by the adhesions from her surgery in 2011. At approximately 15:30 on 5 September 2022 Mrs Hammon began to complain of severe abdominal pain and at 17:52 a CT scan was requested to investigate the cause of the pain. Thereafter, the plan was for the oncoming night shift to arrange for a senior clinical review of Mrs Hammon and to chase the CT scan. However, the plan was not implemented and Mrs Hammon was not seen by the oncoming night shift until 01:00 on 6 September 2022 when she was found to have blood and pus coming out of an old surgical scar, for which she was commenced on intravenous antibiotics. At 02:41 on 6 September 2022 the CT scan was reported as being strongly suggestive of mesenteric iscahaemia with infarction complicating a known small bowel obstruction and thereafter at 10:50 on 6 September 2022 Mrs Hammon underwent an emergency laparotomy, during which the surgical team found widespread ischaemic bowel, and resected a significant amount of her small bowel. On 7 September 2022 a further relook laparotomy was carried out after which Mrs Hammon was cared for on the Intensive Care Unit, however, her condition deteriorated and she died at St. Peter’s Hospital on 9 September 2022. Her death was due to Multi-Organ Failure due to Non Occlusive Mesenteric Ischaemia. The ischaemia was caused by the small bowel obstruction which in turn was caused by adhesions from her surgery in 2011. The small bowel obstruction caused the ischaemia firstly by impairing the blood flow within the lining of the bowel and secondly by causing Mrs Hammon to become dehydrated, due to vomiting and reduced fluid absorption from the bowel, which in turn led to her developing hypovolaemia, acute kidney injury and low blood pressure, which prompted her body to reduce the blood supply to the bowel in order to protect other major organs. Mrs Hammon’s death was contributed to by her Chronic Kidney Disease which made her more susceptible to developing acute kidney failure. During the period from 1 September 2022 onwards there was a failure to accurately monitor Mrs Hammon’s fluid input and output which led to a failure to provide her with adequate fluid replacement, which contributed to her developing dehydration and related bowel ischaemia. During the same period there was a failure to identify that Mrs Hammon’s blood tests showed high CRP levels, which is a non-specific inflammatory marker and can be consistent with bowel ischaemia. By 4 September 2022 the clinical team caring for Mrs Hammon ought to have recognised that she had ongoing unexplained high CRP levels, in the context of an ongoing small bowel obstruction, with ongoing vomiting, a return of abdominal discomfort and a deteriorating kidney function. Those matters ought to have prompted a senior clinical review and a CT scan which would have diagnosed bowel ischaemia and resulted in emergency surgery on 4 September 2022. Had Mrs Hammon been taken for surgery on 4 September 2022 she would have survived. On the afternoon of 5 September, when Mrs Hammon developed severe abdominal pain, she ought to have received a senior clinical review which would have prompted an expedited CT scan which would have diagnosed ischaemia and would have resulted in emergency surgery on the night of 5 September 2022. Had Mrs Hammon been taken for surgery on 5 September 2022 she would have survived. Mrs Hammon’s death was contributed to by neglect. 5 CIRCUMSTANCES OF THE DEATH The circumstances of Mrs Hammon’s death are set out in the narrative conclusion above. 6 CORONER’S CONCERNS The MATTER OF CONCERN is: 1. Mrs Hammon’s rising CRP was not noted by any member of the clinical team – whether junior or senior - who saw Mrs Hammon during the period from 1 September onwards, despite rising CRP being a potential indicator of ischaemia in patients who are being conservatively managed for small bowel obstruction. The court is concerned that this was not an individual error and may be reflective of a wider lack of knowledge within the team. 2. The fluid input and output charts completed for Mrs Hammon were inadequate and could not be relied upon to accurately assess her fluid input and output. 3. The Early Warning Scores (NEWS2 Scores) for Mrs Hammon were often incomplete. The court did not receive any reassurance from the Trust during the course of the inquest that these matters have been addressed following Mrs Hammon’s death. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. , Interim Chief Executive, Ashford and St. Peter’s Hospitals NHS Foundation Trust 2. Chief Coroner 3. Mrs Hammon’s family 10 Signed: ANNA CRAWFORD Anna Crawford H.M Assistant Coroner for Surrey Dated this 30th day of July 2024
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.
Our Ref: Date: 20 September 2024 Miss Anna Crawford HM Assistant Coroner for Surrey HM Coroner’s Court Station Approach Woking GU22 7AP Dear Miss Crawford St Peter’s Hospital Guildford Road Chertsey Surrey KT16 0PZ DX 119775, Chertsey 2 Tel Web www.ashfordstpeters.nhs.uk Text Relay Re: Mrs Wendy Hammon Regulation 28 Report to Prevent Future Deaths Please find below my responses to your concerns raised in your email received on 29 July 2024 following the inquest into the death of Mrs Wendy Hammon. The Regulation 28 report sets out the matters giving rise to concerns numbered 1-3 below. 1. The fluid input and output charts completed for Mrs Hammon were inadequate and could not be relied upon to accurately assess her fluid input and output. 2. Mrs. Hammon’s rising CRP was not noted by any member of the clinical team – whether junior or senior - who saw Mrs Hammon during the period from 1 September onwards, despite rising CRP being a potential indicator of ischaemia in patients who are being conservatively managed for small bowel obstruction. The court is concerned that this was not an individual error and may be reflective of a wider lack of knowledge within the team. 3. The Early Warning Scores (NEWS2 Scores) for Mrs Hammon were often incomplete. Serious Incident Report Following the Inquest, the Trust’s Serious Incident Investigation Report has been completed and a copy is attached which I hope you will find helpful. The report incorporates key issues identified during the Inquest and has recommended the Junior Doctors be empowered to escalate and seek senior review. To facilitate this the following actions will be discussed at the Junior Doctor Forum as a regular standing agenda item. • Clear concise documentation to be a standard process. • Importance of escalating unwell patients by junior doctor team members and nursing staff to senior surgical team members (registrar or consultant) and barriers to doing so. • Reinforcing the importance of the senior clinical teams that are available on site all the time. In addition to the surgical registrar who is on site 24 hours a day, 7 days a week, there is the CSNP team, who are advanced practitioners and can support junior staff and get senior staff to the patient when required. ITU staff can also be contacted if the critical care outreach team is unavailable. Patients first Personal responsibility Passion for excellence Pride in our team • Escalation and chasing of urgent CT scans with the radiology department. 1. Fluid Balance The Trust has also implemented the following improvements in relation to the accurate monitoring of fluid balance in patients’ healthcare records since September 2022. In May 2022 the Trust moved to an electronic patient record (EPR). Before this, the Trust used daily paper hard copy fluid balance charts for each patient that required fluid intake and output monitoring. It was identified that the fluid balance area of the EPR does not automatically populate the fluid balance chart when parenteral nutrition is commenced. To manage this a quick reference guide (QRG) - appendix 1 - was developed and widely disseminated throughout the Trust. Fluid Management is a high priority on the list of projects for the Medication Administration Process within EPR which will commence in October 2024 following an EPR system upgrade. The Electronic Prescribing and Medicines Administration (EPMA) Pharmacists are undertaking work as part of a Discovery Phase to provide the EPR team with the fullest information to enable them to proceed. The EPR team will work with Subject Matter Experts (SME) to understand what needs to feed through to the fluid balance chart. A gap analysis will follow this to identify the updates needed to improve the accessibility and the viewing of the fluid balance chart. A secondary project to implement clinical support decisions to help the identification of patients who are at risk of hydration or renal issues will also be required. New clinical staff to the Trust have training in accurate monitoring of fluid balance as part of the induction training (for Health Care Support Workers, newly registered nurses, and Internationally Educated Nurses). This training forms part of the Care Certificate for Health Care support workers and the Preceptorship competencies of newly registered nurses and internationally educated nurses. Student Nurses allocated to the Trust receive additional training on induction which consists of a workbook that includes how to complete fluid charts and the importance of accurate fluid balance records for patient care. Ward based Clinical Practice Educators work alongside staff with all aspects of nursing care including accurate recording of fluid balance and how to record this on the EPR. The importance of fluid balance has been discussed at daily safety huddles across the wards. This has also been a focus of the ward's ‘Big 3’ where three important topics that are the focus for a week are discussed at all handovers and will be repeated at intervals until embedded in practice. One ward has implemented a set time for emptying catheters, drains, and NG tubes to ensure output is recorded. Staff are expected to review charts before the end of each shift and the ward manager is monitoring compliance with this. The ward is also working on a quality improvement project to improve patient oral hydration and fluid balance. Both of these quality improvement initiatives will be rolled out across the Trust once their benefit and success are evaluated. The divisional Clinical Practice Educators are providing ward focused education in the form of tea trolley training to ensure all staff are educated in the accurate recording of fluid balance. Review of fluid balance charts forms part of the weekly care round where senior nurses visit each ward providing support and guidance in completing all aspects of the patient's EPR. Patients first Personal responsibility Passion for excellence Pride in our team 2 & 3 Deteriorating Patient Working Group A Trust wide Deteriorating Patient Working Group has recently commenced to address concerns around recognising, escalating, and managing the deteriorating patient. The group has representation from all clinical areas, medical, nursing, and allied health professionals, practice educators and training leads, and digital leads. The group is focussed on leading improvements in the following areas. • Supporting the identification of and understanding of the barriers to recognition of the deteriorating patient across all patient groups. • Reviewing and updating policies and guidance related to the recognition, escalation, and management of deteriorating patients and sepsis. • Support and oversight of the training and education provided to clinical staff in relation to the recognition, escalation, and management of the deteriorating patient, including. o Vital sign observation recording, monitoring, and escalation o Appropriate and full NEWS2 scoring and escalation o Recognition and escalation of abnormal blood results (including CRP being a potential indicator for bowel ischaemia) • Reviewing and strengthening the escalation process embedded with the electronic patient record, including; o Sepsis tools and alerts o NEWS2 alerts • Monitoring change and quality improvement projects that are specifically aimed at improving the recognition and escalation of the deteriorating patient including; o Understanding of NEWS2 and Sepsis escalation procedures o Escalation for senior review, critical care outreach referral, and hospital at night support. o Undertaking and documentation of full vital sign observations and NEWS2 scoring o Monitoring and escalation of abnormal blood results (including CRP) The group will meet regularly to monitor progress against these areas for improvement and report to the Trust Safety and Quality Committee bi-monthly. I hope the changes the Trust has made to our practices are sufficient to demonstrate we have taken your concerns seriously and continue to take action to learn and improve the concerns you have raised in your report. Please do not hesitate to contact me should you require further details or documentation. Yours sincerely Chief Executive Officer Patients first Personal responsibility Passion for excellence Pride in our team Appendix 1 Patients first Personal responsibility Passion for excellence Pride in our team
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