Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0512, written 24 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Sep 2024 |
|---|---|
| Reference | 2024-0512 |
| Deceased | Kelly Stevens |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD; 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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 21 February 2024 I commenced an investigation and opened an inquest into the death of Kelly Marie STEVENS. The investigation concluded at the end of the inquest on 24 September 2024 The conclusion of the inquest was that Ms. Stevens “Died from complications associated with an excessively low, and unrecognized, sodium level while in hospital. Her death was contributed to by neglect.” 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Ms. Stevens come by her death?”, I recorded as follows: “On 28.12.23 Kelly Stevens, who lived with profound learning and physical disabilities, and received all nutrition, hydration and medication via a percutaneous endoscopic gastrostomy ( PEG ) tube, was admitted to Worcestershire Royal Hospital with abdominal distension and concern about her PEG tube. She was diagnosed with a likely pseudo-bowel obstruction and a plan was made for her to undergo endoscopic investigation. In the meantime, she was prescribed intravenous fluids but her intake of these was not properly recorded, and her electrolyte levels were not monitored. On the morning of 3.1.24 she suffered a seizure during which she aspirated some vomit. This seizure was caused by an excessively low sodium level which had not been recognized. She went on to develop aspiration pneumonia and, despite treatment, declined and died in hospital later that night.” 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 will 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) Despite being under the care of the medical team, Ms. Stevens did also receive input from the surgical team. Her situation was further complicated by the fact that for most of her admission she was placed as a medical outlier on 1 a surgical ward. In the event, no one consultant was in overall charge of her care, which meant that the issues identified in this case were not picked up on. I heard evidence that there was no policy in place at the Trust to give guidance as to how this sort of situation should be resolved, but instead that it was expected that consultants would liaise with each other in order to do so. That did not happen in this case; 2) No doctor providing care for Ms. Stevens followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes. In Ms. Stevens’ case, this was particularly important because her baseline sodium level was low anyway, so the overprescription of fluids put her at greater risk of hyponatraemia; 3) There was no proper recording of Ms. Stevens’ fluid intake and output on fluid balance charts for most of her hospital admission. For the reasons set out at 2) above, this was vitally important in her case; 4) Ms. Stevens’ hospital notes revealed evidence of the routine “copying and pasting” of out-of-date care plans by previous doctors. This meant that the next person reading her notes would be left with an erroneous view of her current care plan. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of Worcestershire Acute Hospitals NHS Trust, 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 19 November 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: (a) (b) Dimensions UK, who run the supported living accommodation where Ms. , Ms. Stevens’ mother; Stevens’ lived; (c) The Care Quality Commission. 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 24 September 2024 David REID HM Senior Coroner for Worcestershire 2 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.
08 November 2024 Mr David Reid HM Senior Coroner Worcestershire Coroners Court The Civic Martin’s Way Stourport on Severn Worcestershire Sent via email: Dear Mr Reid Re Regulation 28 Report to Prevent Future Deaths Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 16th October 2024, following the Inquest touching on the death of Kelly Stevens. In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT). 1) Despite being under the care of the medical team, Ms. Stevens did also receive input from the surgical team. Her situation was further complicated by the fact that for most of her admission she was placed as a medical outlier on a surgical ward. In the event, no one consultant was in overall charge of her care, which meant that the issues identified in this case were not picked up on. I heard evidence that there was no policy in place at the Trust to give guidance as to how this sort of situation should be resolved, but instead that it was expected that consultants would liaise with each other in order to do so. That did not happen in this case; 2) No doctor providing care for Ms. Stevens followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes. In Ms. Stevens’ case, this was particularly important because her baseline sodium level was low anyway, so the overprescription of fluids put her at greater risk of hyponatraemia; 3) There was no proper recording of Ms. Stevens’ fluid intake and output on fluid balance charts for most of her hospital admission. For the reasons set out at 2- above, this was vitally important in her case; 4) Ms. Stevens’ hospital notes revealed evidence of the routine “copying and pasting” of out-of-date care plans by previous doctors. This meant that the next person reading her notes would be left with an erroneous view of her current care plan. RESPONSE: 1) At the time of the incident, there was no policy in place for the management of medical outliers. In the action plan of the report the Chief Medical Officer (CMO) has an action relating to the review of a patient outlier policy and to taking over patient care. These actions are almost completed. Meetings were held between the senior clinical leaders and the Chief Medical Officer on 11th October 2024 and the 4th November to review the policy. The policy has been agreed and will be shared through the Improving Safety Actions Group (ISAG) on 14th November 2024 and approved through Trust Management Board on 20th November 2024 with immediate implementation thereafter. Any issues with outliers are escalated via the capacity meetings/the flow WhatsApp group which is monitored on a daily basis by the bed lead for the Division. This process is followed Monday to Friday and ensures any issues with either review or management of outlier patients are picked up in a timely manner. 2) Blood monitoring training is included as part of the core medical curriculum covered within medical training. 3) There have been multiple actions to improve fluid balance records: • A Trust wide “Lesson of the Week” was shared on 5th August 2024 to share learning and actions required to support immediate improvements in Fluid Balance documentation in EPR. • Additional opportunities for education around nutrition and hydration are included throughout the ward: o Local induction to the ward for Healthcare Assistants (HCA) covers MUST and fluid balance; this is an informal local training and is completed with the Band 6. o Fluid balance training provided by the Acute Kidney Injury nurse. o Rolling HCA study day programme which includes MUST and nutritional risk. o Due to changes with fluid balance and the introduction of EPR, the Division recognise there is a gap in training; the Division are currently formulating a training package to be delivered locally. o Training compliance will be monitored through the Nutrition and Hydration steering group, a trajectory has been submitted to improve compliance with training over the next 3 months to provide assurance around learning 4) The copy forward function on EPR was removed from 3 documents on 14th May 2024: Medical Clerking, Ward Round and Specialty Review. Copy forward was then removed from all documents within the EPR system on 4th September 2024. I hope that the above addresses the concerns which you raised. I have no representations in respect of publication of the Regulation 28 or this response by the Chief Coroner. I shall be grateful if you could kindly send a copy of my response to anyone to whom you copied your Regulation 28 report. Yours sincerely Chief Executive
See every Prevention of Future Deaths report matching Worcestershire Acute Hospitals NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.