Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0461, written 20 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2024 |
|---|---|
| Reference | 2024-0461 |
| Deceased | Susan Williams |
| Coroner | Paul Bennett |
| Coroner area | Carmarthenshire & Pembrokeshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE PEMBROKESHIRE & CARMARTHENSHIRE CORONER’S COURT REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Clinical Director, Hywel Dda University Local Health Board, Ystwyth Building, Hafan Derwen, St David’s Park, Jobswell Road, Carmarthen, SA31 3BB 2. The Chief Executive NHS Wales, Welsh Assembly, Cathays Park, Cardiff, CF10 3NQ 1 CORONER I am Paul Bennett, acting senior coroner, for the coroner area of Pembrokeshire & Carmarthenshire 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 the 14th February 2020 I commenced an investigation into the death of Susan Margaret Williams aged 73. The investigation concluded at the end of the inquest on 19th June 2024. The conclusion of the inquest was a natural causes one with the medical cause of death recorded as: 1a. Cardiorespiratory failure. 1b. Lung Fibrosis. Cor Pulmonale. 4 CIRCUMSTANCES OF THE DEATH Susan Margaret Williams had been admitted as an emergency patient at 4.23am on the morning of the 14th July 2019 into the Accident and Emergency Unit of Withybush Hospital, Haverfordwest with a suspected diagnosis of sepsis, complaining of abdominal pain. She underwent care and treatment consistent with that diagnosis. Despite appropriate measures being taken, Mrs Williams deteriorated and died from Cardiorespiratory failure due to lung fibrosis and Cor Pulmonale. 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. – Following initial triage and attendance by a clinician, a number of appropriate medications were prescribed and entered on the In-Patient Medication Administration Record. These comprised an analgesic, an anti-emetic and two antibiotics. 1 1. The Medication Record shows the time that the medications are administered, but not the time that they were prescribed. In this case the evidence showed that the antibiotics were administered later than the other medications and there was a conflict between the prescribing clinician and the nurse administering the medications as to whether all of the medications had been prescribed at the same time. The concern in this case related to a potential delay in the administration of the antibiotic medication (considered to be a significant sepsis treatment), there being a period of some 90 minutes between the times entered on the Record for the administration of the analgesia and the anti-emetic. I consider this to be a concern as the lack of a recorded time of prescription highlights the possibility that there is no immediate means of referencing whether a prescribed medication has been administered within a reasonable time of it being prescribed. Although the factual findings in this inquest did not show a causative connection between the delays in the administration of the antibiotics, I consider this to be a concern that may result in a potential future death. 2. In the course of the evidence, it also became apparent that the Accident & Emergency Record Card (known as the “Cas Card”) has no similar provision to record medication prescription and administration within its content. This would have been a separate point of reference for this purpose. Both of the documents referenced are understood to be used across the NHS in Wales and not confined to the Health Board in whose care Mrs Susan Margaret Williams was at the time. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you your organisation(s) 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 16th August 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 – Susan Margaret Williams. , the family of Mrs and 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 20th June 2024 2
2 responses 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.
Ein cyf/Our ref: Gofynnwch am/Please ask for: Rhif Ffôn /Telephone: 0300 0200 159 E-bost/E-mail: Dyddiad/Date: 16th August 2024 Dear Mr Bennett Postal address: FREEPOST FEEDBACK@HYWELDDA Thank you for contacting the Health Board on 20th June 2024 regarding Susan Margaret Williams’ care and treatment within Withybush General Hospital (WGH.) I am sorry to hear the treatment Mrs Williams received has given you cause for concern. The Health Board strives to provide the absolute best of care to our patients, and where concerns are raised, it is important that we undertake a thorough review and provide a formal response to you. Where failings are identified, I can assure you that the Health Board is eager to acknowledge this openly, learn lessons and take action to prevent similar incidents occurring again. You have raised two matters in the Regulation 28 Report. First, the medication record/chart in the Emergency Department does not have a box for the time at which medication is prescribed. There are boxes for when the medication is to be given, and a box for when the medication has been given. In Mrs Williams’ case, she was written up for analgesic, anti emetic and two antibiotics by the same Doctor. Time to be given was “stat” (immediately). However, only the anti emetic and analgesia were immediately given. The medication chart in the Emergency Department is a Wales NHS approved chart. Hywel Dda University Health Board is not able to unilaterally change the chart, although it can put forward proposals for variations to the national group. The Learned Coroner will appreciate that this takes quite some time, and we are aware that the issue has been raised with the National Authority directly in a separate, but linked PFD Report. Electronic Prescribing and Medicines Administration System (EPMA) is currently being rolled out in NHS Wales. EPMA will address this issue because it is live system: any intervention which you make will automatically record who carried out the intervention together with the date and time. This is not unlike the Welsh Nursing Care Record (WNCR) with which the Coroner will be familiar. The precise commencement depends on a number of factors including system purchase, roll out and education. In the interim we will implement that the “time to be given” box on the Medication Card (Emergency Department) is always completed with an actual time. Practitioners will be directed not to write “stat”. The time written will be the time when the antibiotic was prescribed, as immediate administration will always be required with intravenous Swyddfeydd Corfforaethol, Adeilad Ystwyth, Hafan Derwen, Parc Dewi Sant, Heol Ffynnon Job, Caerfyrddin, Sir Gaerfyrddin, SA31 3BB Corporate Offices, Ystwyth Building, Hafan Derwen, St Davids Park, Job’s Well Road, Carmarthen, Carmarthenshire, SA31 3BB Cadeirydd /Chair Prif Weithredwr Dros-Dro/Interim Chief Executive Bwrdd Iechyd Prifysgol Hywel Dda yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Hywel Dda Hywel Dda University Health Board is the operational name of Hywel Dda University Local Health Board Mae Bwrdd Iechyd Prifysgol Hywel Dda yn amgylchedd di-fwg Hywel Dda University Health Board operates a smoke free environment antibiotics in this situation. The intention is to roll out these steps rapidly to staff include presentation by Pharmacy at the Grand Round in w/ 12th August 2024. The second matter concerns the A and E Card/ cascard which contains a narrative entry from the clinician. In this case, the entry by the Doctor is dated but not timed. The entry is brief and does not refer to commencing the sepsis six bundle or the decision to prescribe medicines. The entry is not compliant with record keeping policy which states entries need to be timed. The timed entry represents the time of writing that entry in the notes unless annotated otherwise. Clinicians are expected to date and time every separate entry. We would not expect a clinician to write specifically what drugs they are prescribing in the narrative clinical record, though they may write ‘antibiotics’ for example, or the name of a drug in their narrative. The narrative, even if dated and timed, would never trigger a drug being given because the drug chart itself is what carries the legal prescription and includes dose, route, signature, and time to be given. In respect of this second issue, we have sent an email to all clinicians reminding them of the Health Board’s policy on clinical record keeping standards. An audit will be carried out to ensure adherence. The Health Board is grateful for you bringing these concerns to our attention, as it allowed us to make relevant changes, to prevent similar events reoccurring. Action has been taken to address the issues identified. Please do not hesitate to contact the Health Board again should you require any further information. Yours sincerely Interim Chief Executive
Cyfarwyddwr Cyffredinol Grŵp Iechyd, Gofal Cymdeithasol a'r Blynyddoedd Cynnar / Prif Weithredwr GIG Cymru Director General Health, Social Care & Early Years Group / NHS Wales Chief Executive Paul Bennett Acting Senior Coroner for Pembrokeshire and Carmarthenshire Pembrokeshire County Council County Hall Haverfordwest SA61 1TP By email to: Dear Mr Bennett Your Reference: 06 August 2024 Regulation 28 Report to Prevent Future Deaths – Susan Margaret Williams Thank you for your letter (dated 21 June 2024) enclosing the Regulation 28 report following your investigation into the death of Susan Margaret Williams at Withybush hospital, Haverfordwest which concluded on 19 June 2024. I was sad to hear of the passing of Ms Williams and give my condolences to the family. I note you have also sent your Regulation 28 report to Hywel Dda University Health Board (HDUHB), This reply is from a Welsh Government perspective, I would also expect HDUHB to reply separately to you on this. I will respond to both matters raised within your Regulation 28 report for the Welsh Government in this letter. The first point in your Regulation 28 report notes your concern that the absence of a requirement to indicate the time at which a medicine is prescribed on the hospital medication administration chart, which is used for prescribing and recording medicines administered in all hospitals in Wales, means there is no means of determining whether medicines are administered within a reasonable time of them being prescribed. The information which must be included on prescriptions is set out in regulation 217 of the Human Medicines Regulations 2012 as amended. Whilst there is no requirement for a prescription to contain the time a medicine was prescribed, there are clearly situations in which specifying an exact time for administration is important for the appropriate care of individual patients. The ARK hospital medication administration record which has been in Parc Cathays ● Cathays Park Caerdydd ● Cardiff CF10 3NQ Gwefan ● website: www.gov.wales use since 2022, includes features to ensure time critical medicines are administered at the appropriate time. These features include: • A dedicated section on the front of the chart for so-called ‘stat’ or immediate doses to be recorded which includes space to indicate the time the medicine is to be given. In general, where an antibiotic is to be given urgently outside the regular dosing regimen, it should be recorded here; and • A dedicated section for antibiotic courses to be prescribed and their administration recorded which allows for the dosing regimen to be recorded with reference to the time of the day i.e. morning, midday, evening and bedtime, or where required, a specified administration time. There are inherent risks with hard copy charts and one of the reasons why in September 2021, the Cabinet Secretary for Health and Social Care announced plans to introduce electronic prescribing and medicines administration (EPMA) systems in every hospital in Wales. All health boards are in the process of implementing EPMA solutions in their hospitals and Digital Health and Care Wales has confirmed both EPMA solutions being deployed in Wales record a timestamp for all activities which make alterations or add data to prescribing records. This includes prescribing and administration events. In future prescribing and administration events will therefore be fully auditable. Both EPMA solutions allow the production of task lists enabling those administering medicines to identify which medicines are due at any given time and any medicines which have been prescribed and which should have but have not yet been administered. An EPMA system is already in use in one health board area with two further health boards about to begin their implementation. HDUHB will shortly be beginning the implementation. All health boards are expected to begin implementation by the end of 2025. In relation to your second point in your Regulation 28 report, the medication prescription records in emergency departments, currently in addition to the KAS card, requires all patients who are to be transferred from emergency departments to inpatient wards should have a medication administration record written for them which includes details of any medicines prescribed, administered and to be continued following transfer to another department of the hospital. The roll out of EPMA will facilitate the seamless transfer of this information either within a single prescribing solution or interoperable solutions deployed to emergency departments and inpatient wards. This will remove the need for a separate medication administration record to be provided with the KAS card. Yours sincerely
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