Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0547, written 14 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2024 |
|---|---|
| Reference | 2024-0547 |
| Deceased | John Follon |
| Coroner | Gaynor Kynaston |
| Coroner area | South Wales Central |
| 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 | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
Telephone:
Email:
ANNEX A
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:
The Chief Executive Cardiff & Vale University Health Board
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CORONER
I am Gaynor Kynaston Assistant Coroner, for the coroner area of South Wales Central.
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.
INVESTIGATION and INQUEST
On 5 December 2022 I commenced an investigation into the death of John Austin FOLLON .
The investigation concluded at the end of the inquest 08/10/2024 . The conclusion of the
inquest was Mr John Follon, a 78year old gentleman was admitted to hospital from the GP
surgery having suffered a MI. He underwent successful stenting to remove the blockage.
Four days later, he suffered a cardiac arrest from which he did not recover. Prior to the
cardiac event, a lead from the monitor had become disconnected, the alarm was silenced
by a staff member who did not then check on Mr Follon leading to a period of an hour and
three quarters during which he was not monitored. The cause of the cardiac arrest cannot
be established and it is not possible to determine whether the lack of monitoring more than
minimally contributed to his death..
1a Inferior ST Elevation Myocardial Infarction
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn
Fax/Ffacs
1b
1c
II Hypertension, Chronic Smoker
CIRCUMSTANCES OF THE DEATH
Mr John Follon, a 78 year old gentleman attended his GP surgery with chest pains and
breathlessness on 17 Nov 2022. Following an ECG, which showed he had suffered an
inferior myocardial infarction, he was transported by emergency ambulance from the
surgery directly to the catheter laboratory at The University Hospital of Wales where he
underwent a stenting procedure to unblock the right coronary artery. He made good
progress following the procedure to the point of independently caring for himself on the
ward. However, the monitor showed intermittent 1st degree and complete heart block and a
decision on whether he required a permanent pacemaker depended upon the extent of his
recovery. While awaiting this decision, he was being monitored on CCU by telemetry. On
21 Nov 2022 at 06:57, one of the leads became disconnected triggering an alarm at the
nurses station which was acknowledged at 07:04 and silenced by a staff member. The
evidence suggests that person did not check on Mr Follon at that time. Mr Follon was last
spoken to on or around 07:30hours before being found unresponsive in a state of cardiac
arrest in his bed at 08:45hrs. Resuscitation was commenced, however, it was not
successful and he passed away at 09:06. Neither the cause nor time of the cardiac arrest
can be established as he there was no monitoring during the period from when the lead
became detached until his death.
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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) Changes to the alarm system have been made following Mr Follon’s death such as
making the alarm louder and ensuring a yellow ribbon appears and remains at the top of
the monitoring screen until the alarm is reactivated. However, it is still possible for a
member of staff to silence the alarm without checking on the patient and the alarm will
remain silent until it is physically reactivated by a member of staff.
5
(2) Currently when the alarm is triggered, during the day shift, staff are required to check
on the patient prior to the alarm being silenced, during a night shift staff are permitted to
silence the alarm prior to checking the patient to reduce noise to a minimum while patients
are sleeping. The latter was the position in the instant case when Mr Follon’s lead became
detached.
(3) The monitors are not checked constantly or even every hour but are checked twice
during each shift. During a busy night shift or during handover, if the person silencing the
alarm does not attend to the patient at the time the alarm sounds and if the amber ribbon,
which now appears on the monitor alerting staff to a “lead off” scenario, goes unnoticed, the
risk that a patient will not be monitored for a significant period of time remains.
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn
Fax/Ffacs
(4) During a night shift, the circumstances in which Mr Follon died remain the same
notwithstanding changes to nursing practice and the alarm system have been made. The
risk of a patient not being monitored for a significant period of time remains and could give
rise to a death in similar circumstances in the future.
ACTION SHOULD BE TAKEN
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In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 8th December 2024 only 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.
COPIES and PUBLICATION
Chief Executive Officer,
, Cardiff and Vale University Local Health Board
I have sent a copy of my report to family who may find it useful or of interest.
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.
14 October 2024
SIGNED:
Gaynor Kynaston Assistant Coroner for South Wales Central Coroner Area
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn
Fax/Ffacs
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.
Q G IG Bwrdd lechyd Prifysgol Executive Headquarters / Pencadlys Gweithredol ojo Caerdydd a‘r Fro Woodland House Ty Coedtir ; Maes-y-Coed Road Ffordd Maes-y-Coed N H S Cardiff and Vale Cardiff Caerdydd University Health Board = ¢F14 4HH CF14 4HH Eich cyf/Your ref: 9691348 Ein cyf/Our ref: SR-jb-1224-032 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Chief Executive 6 December 2024 Private and Confidential Ms G Kynaston Assistant Coroner Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Dear Ms Kynaston Thank you for your letter received via email received 17 October 2024 in which you have shared the Regulation 28 with associated actions for improvement following the inquest into the sad death of Mr John Austin Follon. | note that it is your view that some actions could be taken by the Health Board to minimise the risk of future deaths in similar circumstances. In addition, it is noted that the cause of the Cardiac arrest cannot be established and it is not possible to determine whether the lack of monitoring more than minimally contributed to this gentleman's death, the Health Board accepts that this is unsatisfactory for the family and did not assist the inquest process. The matters of concerns raised are outlined: (1) Changes to the alarm system have been made following Mr Follon’s death such as making the alarm louder and ensuring a yellow ribbon appears and remains at the top of the monitoring screen until the alarm is reactivated. However, it is still possible for a member of staff to silence the alarm without checking on the patient and the alarm will remain silent until it is physically reactivated by a member of staff. In the inquest it was acknowledged by the CVUHB (Cardiff and Vale University Health Board) representative that these measures taken would not in isolation prevent a reoccurrence of this event. It is hoped that the additional measures taken as outlined in this response will provide some further reassurance. Be disability , , i confident Bwrdd lechyd Prifysgol Caerdyde a'r Fro yw enw gweithredol Bwyrlid techyd Ueol Prifysgol Caerdydd a'r Fro EAasiGvER Cardiff and Vale University Health Board is the operatignal name of Cardiff and Vale University Local Health Board Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saosneg Sicthaws byddwn yn cyfathreby 4 chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw ood The Board watcomes correspondence in Walsh or Engish. We will ensure that wa will communicate i your chasen fanguage. Correspondence in Welsh wil not lead (0 @ delay (2) Currently when the alarm is triggered, during the day shift, staff are required to check on the patient prior to the alarm being silenced, during a hight shift staff are permitted to silence the alarm prior to checking the patient to reduce noise to a minimum while patients are sleeping. The latter was the position in the instant case when Mr Follon's lead became detached. We would like to advise that there is no formal permission given to staff to silence the alarm before reviewing the patient at any time of day or night. Staff will often silence the alarm prior to reviewing the patient to reduce noise levels for the comfort of all patients however the issue that arose in this situation was that the alarm was silenced but the cause of the alarm was not clarified and Mr Follon was not reviewed as would have been expected in these circumstances. (3) The monitors are not checked constantly or even every hour but are checked twice during each shift. During a busy night shift or during handover, if the person silencing the alarm does not attend to the patient at the time the alarm sounds and if the amber ribbon, which now appears on the monitor alerting staff to a “lead off’ scenario, goes unnoticed, the risk that a patient will not be monitored for a significant period of time remains. It may be helpful to clarify the monitors are observed regularly throughout the shifts but there is a checklist in place to review alarm settings and confirmation that alarms are on. The monitors are also checked outside of this process. (4) During a night shift, the circumstances in which Mr Follon died remain the same notwithstanding changes to nursing practice and the alarm system have been made. The risk of a patient not being monitored for a significant period of time remains and could give rise to a death in similar circumstances in the future. On review it was acknowledged that these circumstances could equally apply to a day shift and we fully acknowledge the above. However, following a number of meetings with our CVUHB clinical engineering department and the monitor manufacturer Phillips following receipt of the regulation 28 further amendments have been made to the system to mitigate the risk of this incident happening again. These actions include: There are two alarm reminder (re-alarm) settings; available for “All inop alarms”; and “Yellow + red alarms”. Once set, this will cause a silenced alarm to reactivate after 2 mins should the alarm condition not be resolved. Yellow + red alarms already have the re-alarm setting on in CVUHB. Our immediate action after the incident was to make the ECG leads off / Lead set unplugged alarms a yellow alarm. This ensures staff can prioritise confirmed red alarm conditions, for example Cardiac arrest alarms. We have ensured that staff are reminded again to deal with a lead off scenario should the alarm be acknowledged but the issue persists. fig deobil ry Bwrdd lechyd Prifysgol Caerdydd a'r Fro yw enw gweithredol Bwyrdd Iechyd Leol Prifysgol Caerdydd a’r Fro | confident Cardift and Vale University Health Board is the operational name of Cardiff and Vale University Locat Health Board stu] Croesawir y Bwrdd chebiaoth yn Gymrasg neu Seesneg Sicrhawn byddwn yn c ylathrebu 4 chi yn eich dewis iath. Ni fydd gohebu yn Gymraeg yn creu unrhyw sat The Board welcomes correspondence m Welsh or English. We will ensure that we will communicate in your chosen language Correspondence i Welsh will not ead Io @ delay The alarm configuration for telemetry units is managed by the central station. The changes to these have been completed within the Cardiothoracic areas on 22 November 2024 by Phillips and the CVUHB Clinical Engineering team. Now that this work is complete, the next stage is to adjust the monitor configurations to match the central station and telemetry configuration; Clinical Engineering will visit the clinical areas to install these configurations onto the monitors. This will require a phased approach to maintain patient safety. All clinical wards in the Cardiothoracic Directorate will be complete by the assigned deadline of 8 December 2024. The subsequent steps after resolving the immediate Regulation 28 actions is to assess and evaluate the configurations across all patient monitoring in CVUHB. In the first instance this will provide us with a more robust understanding of the current configurations. Secondly, we can decide if the changes implemented in the Cardiothoracic areas (yellow priority of leads off/unplugged, and re-alarm for the same) are applicable cross the Health Board. The Directors of Nursing have been asked by the Executive Nurse Director to scope and consider this regulation 28 in light of their own clinical areas and this work will be monitored via the Directors of Nursing forum. It is also our intention to share this information through the Inquest and HOPE (Head of Patient Experience) networks as this could be beneficial across Wales. 1! hope that this information is helpful and offers the assurance you are seeking regarding the improvements instigated to reduce the risk that patients in similar circumstances to Mr Follon will not have the alarm silenced without being checked and reviewed. Yours sincerely Chief Executive confid Bwrdd Iechyd Prifysgot Caerdydd af Fro yw enw gweithredal Bwyrdd lechyd Lleol Prifysgol Caerdyitit a’r Fro meeoraraa lent ardiff and Vale University Health Board is the operational name of Cardiff and Vale University Loca! Health Board Croesamir y fherdd ohebiseth yn Gytnreeg neu Saesneg Sicrhawn bydn yn cytathrebu & chi yn eich dewss iaith. Ni fydd gahebu yn Gymraeg yn pres unrhyw ced? The Board melcomes correspondence m Walsh or Engksh We mil ensure that we wal communicate m your chosen language. Correspondence in Weish wil not Jead to a delay
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