Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0583, written 28 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 | 28 Oct 2024 |
|---|---|
| Reference | 2024-0583 |
| Deceased | Ian Hegarty |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| 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.
Prevention of Future Deaths Report Ian Gilmore HEGARTY (date of death: 17 June 2024) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Group Chief Executive Barts Health NHS Trust Executive Offices Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 17 June 2024, an investigation was commenced into the death of Ian Gilmore Hegarty, then aged 89 years. The investigation concluded at the end of an inquest heard by me on 23 October 2024 at Poplar Coroner’s Court. The inquest concluded with a short-form conclusion of ‘accidental death’. The medical cause of death was: 1a hypovolaemic shock 1b traumatic fracture of right femur 1c frailty syndrome, vascular dementia II HIV encephalitis 4 CIRCUMSTANCES OF DEATH Mr Ian Hegarty was admitted to hospital on 5 June 2024, following a fall at home and increased confusion. He did not sustain any traumatic injury as a result of the fall at home. On 14 June 2024, Mr Hegarty was transferred to the Royal London Hospital for management of his underlying health conditions. He underwent a falls risk assessment following admission, which assessed him as being at moderate risk of falls. The ward put mitigation measures in place to address the falls risk, which included being placed in a bay where all four patients were constantly within the sight of an allocated member of staff who was expected to remain in the bay at all times. On 16 June 2024, the allocated member of staff left bay. In doing so, they did not follow the protocol that had been put in place to reduce the risk of falls for all patients in that bay. During the period of time in which the allocated member of staff was not within the bay, Mr Hegarty had an unwitnessed fall, causing him to sustain a fracture to his right neck of femur. Shortly after the fall, Mr Hegarty’s blood pressure dropped. Despite treatment, his clinical condition deteriorated and he died in the Royal London Hospital in the early morning of 17 June 2024. 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 MATTER OF CONCERN is as follows: 1) That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed. I heard evidence that an internal investigation into the matter has been commenced but is not yet concluded. As such, there was insufficient reassurance, at the time of the inquest, that the risk is being addressed. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you 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 the report, namely 9 December 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 the following: 1. ( and – members of Mr Hegarty’s family ) 2. 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. She may send a copy of this report to any person who she 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 Ian Potter HM Assistant Coroner, Inner North London 28 October 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.
2nd December 2024
Private & Confidential
Mr Ian Potter
Assistant Coroner
Coroner Area Inner North London
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
Dear Mr Potter,
Trust Executive Office
Ground Floor
Pathology and Pharmacy Building
The Royal London Hospital
80 Newark Street
London E1 2ES
Telephone:
www.bartshealth.nhs.uk
RE: Regulation 28 Prevention of Future Deaths Report: Ian Hegarty, Ref 2024-0583
I write in response to the inquest dated 23rd October 2024 and the Regulation 28, Prevention of Future
Deaths report to the trust dated 28th October 2024.
We are sorry that Mr Hegarty died at the Royal London Hospital after a fall that caused him to sustain
a fractured neck of femur. At the time of his fall, nursing staff reported it as an incident on our risk
management system, Datix, and it was then reviewed under the Patient Safety Incident Response
Framework (PSIRF). We have taken his fall very seriously and as discussed at the inquest, we are
undertaking a Patient Safety Incident Investigation (PSII).
PSII’s are undertaken to identify opportunity for learning and improvement through providing a clear
explanation of how the organisations systems contributed to his fall. This is currently being undertaken
by senior investigators at the Royal London Hospital. We have allocated a member of staff as the
compassionate engagement lead to support Mr Hegarty’s family through this process and to ensure
that they can be involved in the investigation process as they wish.
Once the investigation is complete, the findings from the PSII will be used to identify actions that will
lead to improvement in the safety of the care future patients will receive. Agreed actions will be
recorded on Datix, so that their completion can be tracked. His family will be offered a copy of the
report to see the action that will be taken.
I would like to assure you that falls are a patient safety priority for the hospital and we have a Quality
Improvement workstream in place for reducing the number of in-patient who fall during an admission.
This is led by one of our Associate Directors of Nursing with support from the hospital Quality
Improvement team. It feeds into our Harm Free Care agenda where we are encouraging all our clinical
teams to share learning so that improvements are made across all our in-patient wards. This chart
shows the reduction in falls that we are continuing to see at the Royal London Hospital and that we
are continuing to monitor monthly through the Safety Committee and performance reviews:
Once the investigation into Mr Hegarty’s fall is completed, the learning will be discussed as part of this
improvement workstream. While this investigation is on-going, I would like share the assurance plan
for the Specialist Medicine division. This was developed in April 2024 and is focusing on several areas
of improvement including the assessment of falls and enhanced care. Please find the document
attached.
I hope this provides you with the assurance that we have taken the events in Mr Hegarty’s care very
seriously but I would be very happy to discuss or clarify any of the above points if you wished.
Yours sincerely
Chief Medical Officer
Appendix – Specialist Medicine Division Assurance Plan
No.
Safety action description
Measure
Action owner
(Enter in the form of a SMART Aims
statement)
of performance
Target
delivery
date
Planned
review
date
1.
Reflective discussion with MDT
• Discussed incident
• Reporting of falls – medical &
nursing
• Post fall assessments & care
• Nursing assessments on
admission (reviewed and updated
as necessary)
• Roles & responsibilities within the
•
team on a shift
Induction of bank shift (per shift
and on introduction to the bank)
• Communication with relatives
• Any barriers to the above
• Any training/support needs
identified
2.
After Action Review
• As per PSIRF protocol, led by
independent Consultant
3. Weekly documentation audits & action
plans
• Weekly assurance meetings with
AdoN/Deputy AdoN
• Attended by Senior Nurses/Ward
Managers/ Matrons/Practice
Development Nurses for all 6
wards within the division
• Weekly submission of
documentation, assessments &
care plans for all fundamentals of
care
• Action plans devised by each
ward in response
• Metrics are stored in teams folder
to share with MDT/ward teams
Deputy AdoN
Completed
17/4/24
Completed
Meeting attended
by staff involved
and completed.
Attendance
recorded.
ADoN
ADoN
Completed
2/5/24
Completed
December
2024
Weekly
AAR process in
place and signed
off at Divisional
level
Assurance that
100% of
assessments are
completed.
A consistent
improvement in
metrics reviewed
weekly.
Robust action
plans in place for
training and
development.
4.
Training, Falls and Enhanced Care risk
assessments
• Senior nurse oversight of
enhanced care
• Focus on ward based training re:
falls assessment, post fall
assessment & care
Assurance by
Senior Nurse that
all members of
staff have a
refresher session
on documentation
training
Senior Nurse &
Practice
Development
Nurse
December
2024
Weekly
5.
MDT ward meeting monthly
Meeting minutes
and action log
Clinical Lead &
Senior Nurse
Commenced
July 2024
Weekly
• Governance discussed e.g.
risks/incidents/staffing/staff
wellbeing
• This incident was discussed at
length
6.
M&M MDT meetings
• This incident discussed at length
in M&M.
Meeting minutes
and action log
Clinical Lead
Existing
meeting
Monthly
7.
Clinical incidents to be discussed in
medical/ nursing handover
• Daily board round to discuss
Handover
documentation
Consultant/
AHP/ Ward
Manager
Commenced
May 2024
Weekly
incidents within the last 24 hours
• Debrief and immediate actions
implemented
8.
Mid shift safety huddle
•
Implementation of mid shift safety
huddle around 2pm. Focus on
patients who are at risk of falls/
acutely unwell/ pressure ulcers/
nutrition & hydration needs. Staff
can escalate any concerns or
training needs. Supernumerary
nurse in charge to provide
support
9.
QI project focussing on handover –
nursing/medical/AHP. Can these be
combined/reviewed?
• QI project to commence
reviewing ward handovers –
medical/nursing and AHP
• Review documentation and white
board processes
• Can these be combined to ensure
a robust MDT handover?
Daily mid shift
safety huddle in
place
Senior Nurse
Implemented
June 2024
Monthly
Completed QI
project with
recommendations
for improvement
Matron
Commenced
August 2024
Monthly
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