Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0463, written 15 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Aug 2024 |
|---|---|
| Reference | 2024-0463 |
| Deceased | Kay Simmonds |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners' (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of Aneurin Bevan University Health Board 1 CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 2 3 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 12/10/2023, an investigation was opened touching upon the death of Kay SIMMONDS The investigation concluded at the end of the inquest on 7/8/2024 The conclusion of the inquest was recorded as Narrative Conclusion: "Kay Simmonds attended the Grange University Hospital in Llanfrechfa on 21/7/2022 with signs of sepsis, arising from an infected central line used for haemodialysis. On 22/7/2022, Kay developed septic shock and should have been admitted to the Intensive Care Unit (ITU). Kay was erroneously transferred to the University Hospital of Wales where there were no ITU beds available. Overwhelmed by sepsis, Kay collapsed and died at the University Hospital of Wales on 22/7/22 at 23:45 hours" The medical cause of death was: la) Sepsis 1b) End Stage renal Failure (Treated) 1c) Type 2 Diabetes Mellitus 2. Ischaemic Heart Disease. 4 CIRCUMSTANCES OF THE DEATH These are described in the Narrative Conclusion in Box 3. 5 CORONER'S CONCERNS The MATTERS OF CONCERN are as follows: - Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements. The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk. 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. At the inquest I heard evidence that, unlike other departments in Aneurin Bevan University Health Board, the Emergency Department is still dependent upon the manual calculation of NEWS observations and relies upon the memory thereafter of nurses to perform observations in a timely fashion. In a busy department this exposes the staff and patients to risks of human error. The evidence I heard was that there is currently no plan to implement the electronic version of the NEWS system in the Emergency Department because it is not compatible with the current computer system. Whilst it is not for the Coroner to determine priorities in resourcing projects , I would bring to your attention that this is not the first failure of the manual NEWS system which has come to light though the inquest process. The clinical staff at this inquest were not aware of this error until it was exposed in court. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 08 October 2024. I, the Coroner, may extend this 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 necessary 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Kay Simmonds • Chief Executive of Cardiff and Vale University Health Board 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 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 DATE 15/8/2024 Signed C:C:J!t,,t.C)t.6-•-4 Caroline Saunders His Majesty's Senior Coroner for the Area of Gwent.
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.
GIG NHS Bwrdd lechyd Prifysgol Aneurin Bevan University Health Board Our ref: Date:08 October 2024 PRIVATE AND CONFIDENTIAL Dear Ms Saunders, I am writing to provide you with the Health Board's response to the Regulation 28: Report to Prevent Future Deaths, following the inquest into the death of Mrs Kay Simmonds. As requested, the information presented below is intended to describe the action taken / being taken to mitigate the risk of future deaths. 1. Action that will be taken to introduce an electronic observation and NEWS recording system within the Emergency Department (ED) at the Grange University Hospital (GUH) The ongoing concerns regarding the manual recording of observations within the Emergency Department at the Grange University Hospital is acknowledged. You will be aware that other clinical areas within the Health Board use an electronic system called CareFlow to electronically record observations to improve patient safety and outcomes. CareFlow Vitals is an electronic observation and decision support system designed to improve patient safety and outcomes. It monitors and analyses patient vital signs to identify deteriorating conditions and provides risk scores to trigger escalation pathways. CareFlow vitals can also generate alerts if there are signs of sepsis and calculate early warning scores based on specific algorithms. Implementing this solution in ED will enhance patient care, provide a complete electronic record through integration with Symphony, improve efficiency and reduce the need for paper and human error. Bwrdd lechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ tts. 01633 436 700 f Bwrdd I echydPrifysgol X. BIPAneurinBevan Rydym yn aoesawu gohebiaeth yn BYrataa9 a aYadwa yn Pala, yn Gymraeg heb °ad] Bwrdd lechyd Prilysgol Aneurin Bevan yw ems taveillvedol Bwrdd lederd Lied Prilysgal Aneurin Bevan. 1\1 1 Clinigol Clinical Aneurin Bevan University Health Board Headquarters, St Cadoc's Hospital Lodge Road, Caerleon, Newport NP18 3XQ 1.01633 436 700 f AneurinBevanHealthBoatd X AneurinBevanUHB We welcome correspondence in Welsh and we WS respond in Wash without delay. Anowin Bevan University Health Board is the operational name n Aneurin Bevan University Local Health Board Bwrdd lechyd Prifysgol Aneurin Bevan University Health Board Currently, observations are recorded in CareFlow in other clinical areas but in ED staff use paper observation charts to record the observations and do not input the observations into a handheld device. NEWS scores are then manually scored, which can occasionally lead to human errors. the nursing documentation To monitor compliance across the ED undertakes daily One Patient One Day audits reviewing all the documentation of a patient. The department also undertakes NEWS audits to monitor compliance and ensure appropriate actions are taken. The Senior Nurse also undertakes Dignity and Essential Care Inspections (DECI) monthly which encompasses a review of nursing documentation across a number of patients. Patients' attendance to the ED are recorded on an electronic patient management system that supports tracking and clinical workflow called Symphony. Symphony currently does not interface with CareFlow meaning the ED is unable to use CareFlow. Patients admitted to assessment units and ward areas are admitted onto the Health Board's Clinical Workstation which does interface with CareFlow. The ED has previously investigated the viability of introducing CareFlow within the department to align with the rest of the Health Board, but due to the functionality of the electronic patient management system used within the ED, this has not been possible. The Urgent Care Division has met with the Health Board's digital team on 29 August 2024 to discuss the requirement and urgency to introduce CareFlow within the ED, this is now a priority for the Division. Following the meeting, a member of the digital team attended the ED on 17 September 2024, to map the current processes and requirements and following this visit the digital team are developing an options appraisal to determine how the recording of electronic observations can be recorded within the ED. The options appraisal will be available by mid-October and will look at the safest, quickest and most cost-effective way to implement e-observations in ED and will include any additional licencing and integration costs. The Bwrdd lechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ 4..01633 436 700 f BwrddlechydPrIfysgol BiHAneurinBevan Rydym yn croesawu gohebirugh yn Gymmeg a byddwn yn ymateb yn Gyrnmeg heb oedi. Bwrdd lechyd Pdlysgol Aroma, Bevan yw ems gweithredol Bwrdd ledwd Ued Prifysgol Aneurin Bevan. Clinigol Clinical Aneurin Bevan University Health Board Headquarters, St Cadoc's Hospital Lodge Road, Caerleon, Newport NP18 3XO, t. 01633 436 700 f AneurineevanHeattnacard X AneurinBevanUHB We welcome cortespondence in Welsh and we wit respond in Welsh without delay. Aneurin Bevan Univensty Health Board W the operational none al Aneurin Beall University Local Health Board. Bwrdd lechyd Prifysgol Aneurin Bevan University Health Board Digital team have made contact with the system suppliers and have received quotes for this work and have also prepared a capital bid and are seeking prioritisation of funding. We would like to reassure you that the Digital team are committed to delivering this project. They have reviewed resources internally, prioritising this over other workload and once they have an approved way forward, will be able to produce a timeline for implementation. I trust that this information reassures you with regard to the matters raised, however, if you require any further information or assurance, please do not hesitate to contact me. Yours sincerely Prif Weithredwr/Chief Executive Bwrdd lechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ 401633 436 700 f BwrddlechydPrityggol X. BIPAneurinBevan Rydym yn mom gohebieeth yn Gymrueg a byddwn yn ymereb yn Gymrseg hob oali. Bwrdd leohyd Prityogol Amain Bevan yw ems grmithredal bard lechyd UNA Prityagol Amain Bevan. VN„ I Clinical Clinigol Aneurin Bevan University Health Board Headquarters, St Cadoc's Hospital Lodge Road, Caerleon, Newport NP18 3XQ kw 01633 436 700 f An eurinBevanHea IthBoard X AneurinBevanUHB We welcome oarresponclence in Welsh end we will respond in Welsh Yelhout delay. Aneurin Bevan Unlvers0 Health Board is the cpereltenel name of Aneurin Bevan University Loral Health Board
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