Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0663, written 2 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2024 |
|---|---|
| Reference | 2024-0663 |
| Deceased | Norma Tellam |
| Coroner | Stephen Covell |
| Coroner area | Cornwall & the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Cornwall Hospitals NHS Trust · Cornwall Partnership NHS Foundation Trust · University Hospitals Plymouth NHS Trust · South West Ambulance Service NHS Foundation 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: 1. Royal Cornwall Hospital NHS Trust 2. Cornwall Partnership NHS Foundation Trust 3. University Hospitals Plymouth NHS Trust CORONER 1 I am Assistant Coroner Stephen Covell, Assistant Coroner for Cornwall & the Isles of Scilly. CORONER’S LEGAL POWERS 2 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 4 INVESTIGATION and INQUEST On 21 April 2023 an investigation was commenced into the death of Norma Ann Patricia Tellam. I concluded the investigation at the end of the inquest on 8 April 2024. The conclusion of the inquest was Accidental Death. The cause of death was; 1a Upper Gastro Intestinal Haemorrhage 1b Proximal Femoral Fracture (operated) 1c Fall CIRCUMSTANCES OF THE DEATH On 22 January 2023 Norma Ann Patricia Tellam suffered an unwitnessed fall near her home sustaining a left proximal femoral fracture. On 23 January 2023 Mrs Tellam underwent surgery at the Royal Cornwall Hospital Truro to repair the fracture using a femoral intramedullary nail together with additional metalwork to stabilise and strengthen the repair. On 1 February 2023 Mrs Tellam was transferred to Liskeard Community Hospital for further rehabilitation with a planned review by the orthopaedic department at the Royal Cornwall Hospital within 6 weeks. On 4 February 2023 clinical staff became concerned that Mrs Tellam surgical hip wound might be infected. Mrs Tellam was sent to the emergency department at Derriford Hospital University Hospitals Plymouth rather than to the Royal Cornwall Hospital where the original operation was carried out. Mrs Tellam was returned to Liskeard hospital on 5 February 2023 after an infection was discounted. On 10 February 2023 Mrs Tellam was sent again to Derriford Hospital with symptoms of a suspected infection. A chest infection was subsequently diagnosed and Mrs Tellam was admitted to Derriford Hospital where she remained until 21 February 2023 having subsequently developed Covid. On 11 February 2023 whilst Mrs Tellam was at Derriford Hospital her hip was x-rayed and reviewed by an orthopaedic consultant who identified some movement in the metalwork from the operation particularly a nail in the femoral head. He anticipated that Mrs Tellam would need to have some extra surgery and that she would be transferred back to the Royal Cornwall Hospital in Truro, where the original operation had been carried out and under whose care she remained, as soon as her chest infection resolved. Mrs Tellam was returned to Liskeard Community Hospital on 21 February 2023 where attempts were made to rehabilitate her and improve her mobility. In the light of issues highlighted by the x-rays taken at Derriford, it would have been good practice to return Mrs Tellam to the Royal Cornwall Hospital for follow up. Mrs Tellam continued to experience significant levels of pain from the hip joint and was x- rayed at Liskeard on 16 March 2023.. The x-ray identified that the nail in the femoral head had moved further and was now protruding into the hip socket. It is likely that the movement was caused by the rehabilitation. The x-ray was discussed with the orthopaedic team at Royal Cornwall Hospital. Mrs Tellam was re-admitted to Royal Cornwall Hospital from Liskeard Community Hospital where she underwent on 23 March 2023 a operation to remove the metalwork from the original operation and subsequent total hip replacement. Mrs Tellam initially made satisfactory progress after the operation however on 16 April 2023 she became very unwell suffering an upper gastro intestinal bleed and died at 0630 on 16 April 2023. It is likely that the bleed was caused by necessary anti-inflammatory and pain killing medication. 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. – 5 1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her. 2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery. 3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care. ACTION SHOULD BE TAKEN 6 7 In my opinion action should be taken to prevent future deaths and I believe your healthcare trust has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 27th January 2025. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 8 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. 2 December 2024 Signature 9 Stephen Covell Assistant Coroner for Cornwall and the Isles of Scilly
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.
Mr Stephen H G Covell HM Assistant Coroner H.M. Coroner’s Office Pydar House Pydar Street Truro Cornwall TR11XU Dear Mr Covell, Chief Governance and Improvement Officer Cornwall Partnership NHS Foundation Trust Carew House Beacon Technology Park Bodmin Date: 7 May 2025 RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your Regulation 28 Report to Prevent Future Deaths (‘the report’) of 2 December 2024 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Norma Ann Patricia Tellam which concluded on 8 April 2024. This response is prepared on behalf of the three NHS provider organisations (Cornwall Partnership NHS Foundation Trust, University Hospitals Plymouth NHS Trust and the Royal Cornwall Hospitals NHS Trust) in receipt of the Regulation 28, following discussion together. Our discussions have also included South West Ambulance Service NHS Foundation Trust (SWAST) who were involved in Mrs Tellam’s transfers by ambulance. It is deeply saddening to hear of the circumstances of Mrs Tellam’s death and the organisations providing her care would like to express their sincere condolences to her family. All the NHS Trusts involved receive Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN Call us on 01208 834 600 | Visit our website at cornwallft.nhs.uk concerns with the utmost seriousness, and we are committed to the provision and continued improvement of high-quality patient care. Matters of concern Concern 1 Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her. Following receipt of the report, Cornwall Partnership NHS Foundation Trust (CFT), who were not present at the inquest but are responsible for Liskeard Community Hospital, reviewed their records with the Hospital Matron and Ward Sister. The records show that shortly before the transfer referred to, Mrs Tellam was recorded as having a raised temperature and it was queried whether this was an infection (which would include sepsis) that required urgent investigation and response. At this time, it was not known if this was a generalised infection, or an infection in the surgical wound. This is corroborated in the clinical record made by SWAST which states ‘It was reported that patient became pyrexic around 15:30 with temp of 38, sats 95 on air, BP150/85, pulse 98, resps 24. Pt was reviewed by OOH at 23:43 due to escalation of pain, shivers and NEWS 2 of 5. It reports on arrival she appeared well, chatting, nil resp distress, appears good colour. Liskeard Community Hospital ‘faces’ the University Hospitals Plymouth NHS Trust (UHP). This means that when a patient in south east Cornwall requires urgent transfer to an emergency acute setting, the hospital commissioned to provide care and treatment to patients, is Derriford Hospital. This hospital is the closest in mileage in comparison to the emergency facility at Royal Cornwall Hospital in Truro (RCHT). Conveyance to hospitals on an urgent basis is provided by South West Ambulance Service NHS Foundation Trust (SWAST) who were consulted following receipt of the report. The decision about where to convey a patient is dependent on clinical need and hospital waiting times. The decision to take Mrs Tellam to Derriford Hospital was the correct one when considering her clinical presentation. Page 2 It would not have been appropriate for the ambulance crew to convey Mrs Tellam to RCHT for review by the orthopaedic team. At the time of the assessment by the crew, it was unclear if Mrs Tellam had an infection in her surgical wound, or a more generalised infection, but it was clear that Mrs Tellam required further assessment and access to an acute care facility, with UHP being the closest hospital for prompt access to healthcare. The clinical records from UHP demonstrate that no surgical revision was required, noting that Mrs Tellam had had a slight displacement of the fracture fixation and had been prescribed antibiotics for a chest infection. On 5 February, Mrs Tellam was transferred back to Liskeard Community Hospital to continue her rehabilitation with consent and had a desire to return home as soon as she could to live as independently as possible. On occasion, if it is considered by community hospital staff that a particular hospital would be a more appropriate transfer destination to ensure continuity of care, this can be shared when the 999 call is made. However, clinical decision-making by the assessing ambulance crew is paramount when considering where to convey a patient. Concern 2 When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery. Following receipt of the report, Mrs Tellam’s UHP clinical records were reviewed, which state that she had been ‘admitted due to Liskeard staff concern re infection, raised body temp and inflammatory markers, not partic tender, no swelling or discharge of the wound. Admit for IV antibiotics then back to Liskeard but caught covid and discharged for further rehab once safe. Mrs Tellam’s care was discussed by CFT and UHP, and it was noted that, during the acute admission, she did not have an urgent need for orthopaedic revision surgery. She had been unwell due to a chest infection and then unfortunately caught covid during her admission. The UHP management plan was for her to have a period of recuperation after her chest infection and prior to consideration of any revision/further surgery on her hip. During that time the aim was for Mrs Tellam to be Page 3 transferred to her original care provider, RCHT, as this is also her local hospital and closer to her relatives. A Consultant Orthopaedic Surgeon reviewed her on the ward at UHP on 14 February 2023 and made a plan for a doctor to doctor handover to the team at RCHT. A referral was on that basis on the same day. On receipt of the referral, the RCHT orthopaedic team discussed a potential admission with their trauma coordinators, and the patient record in UHP documented there was a discussion at 15:00 via telephone. The discussion with the orthopaedic team concluded that community-based hospital care was appropriate, and the transfer to such a hospital should be facilitated by the Cornwall Onward Care Team. Unfortunately, there appeared to be some confusion in the subsequent days where, in the medical records at UHP, the plan was variably referred to as ‘transfer to RCHT’ and ‘transfer to community hospital’. There was no clinical need for further liaison with RCHT regarding Mrs Tellam until around the time of her transfer in March 2023. On 15 and 17 February, whilst at UHP, Mrs Tellam was noted to have a National Early Warning Score (NEWS) of 0 which meant she had no infection markers and was considered stable. On 21 February, she was appropriately to Liskeard Community Hospital with a plan for an out-patient follow up appointment at RCHT. The clinical records show that during her second admission to Liskeard Community Hospital, Mrs Tellam was able to mobilise and move herself to the side of the bed and was able to stand up independently to use the Molift (a patient transfer aid) for transfers and use it to get on and off the toilet. transferred Due to a lack of mobilisation in the following weeks, an x-ray was requested by staff at Liskeard Community Hospital, and this took place on 16 March 2023. On 19 March 2023, Mrs Tellam also reported some pain and an outpatients appointment at RCHT was made for 20 March. Mrs Tellam was unable to be seen on that date but returned to RCHT the following day. We believe events after this time were explored at the inquest. Concern 3 Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care. Page 4 When considering the clinical information from the period of care being reviewed, the transfers between Liskeard Community Hospital and UHP were appropriate based on Mrs Tellam’s clinical presentation. Whilst Liskeard Community Hospital was further away from Mrs Tellam’s home, this was unfortunately the only available setting for Mrs Tellam at the time when a community hospital was considered appropriate for her clinical needs. Mrs Tellam was not transferred following her brief first admission to UHP as the clinical opinion was that she did not require an orthopaedic review. On the second admission to UHP, on 14 February, it is clear that there was clinical discussion and sharing of clinical information between the two acute care hospitals, and on the basis of the clinical presentation she did not require surgical intervention requiring transfer to RCHT but was for community based hospital care. Mrs Tellam returned to Liskeard Community Hospital where she continued to receive support and rehabilitation, which we consider was reasonable based on her presentation. Should the Coroner have any further questions from the public bodies concerned in this report please do not hesitate to contact us. Once again, we extend our deepest condolences to Mrs Tellam’s family. Yours sincerely Chief Governance and Improvement Officer Cornwall Partnership NHS Foundation Trust Signed on behalf of all agencies Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth Page 5
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