Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0059, written 23 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 | 23 Oct 2024 |
|---|---|
| Reference | 2025-0059 |
| Deceased | Jean Thomas |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Wales prevention of future deaths reports (2019 onwards) · 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive of Aneurin Bevan University Health Board 1 CORONER I am Caroline Saunders, Senior Coroner for the coroner area of Gwent. 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 02 November 2023 I commenced an investigation into the death of Jean THOMAS aged 85. The investigation concluded at the end of the inquest on 09 October 2024. The conclusion of the inquest was that: Accident Accident 4 CIRCUMSTANCES OF THE DEATH Jean Thomas fell at home on 20/10/23 and fractured her hip. She underwent surgical fixation but developed post-operative sepsis. Against the background of her underlying medical conditions the infection proved overwhelming and Jean died at the Grange University Hospital in Llanfrechfa on 26/10/2023. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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 MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Jean was known to have significant cardiovascular problems and from her admission there were signs this was worsening. Her blood pressure was low, which would normally be treated with intravenous fluids, but excess fluids would put more pressure on her heart, and thus she was also treated with a low dose of furosemide. The management of Jean’s fluid balance was important for the following reasons; she had heart failure, she had chronic renal failure, she had signs of a superimposing acute kidney injury and she was scoring on the NEWS chart from admission, such that the algorithm required the fluid balance to be monitored. Jean had signs of sepsis. Regulation 28 – After Inquest Document Template Updated 30/07/2021 I find at inquest that Jean’s fluid balance was not monitored, which I determined to be a failure in care. It was not monitored by the nursing or the medical staff. Whilst I could not find that knowledge of Jean’s fluid balance would have altered the outcome, it is a matter of grave concern that this basic nursing care was ignored, and these important clinical indicators not monitored by the medical staff. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 18 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Health Inspectorate Wales I have also sent it to Family Members Of Jean Thomas who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 23/10/2024 Caroline Saunders Senior Coroner for Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Executive Director of Nursing | Gweithredol Cyfarwyddwr Nyrsio
Your ref:
Private & Confidential
Caroline Saunders
Senior Coroner for Gwent
SENT VIA EMAIL:
Dear Ms Saunders
18 December 2024
Re Aneurin Bevan University Health Board response to Regulation 28 Report received
following the inquest touching on the death of Jean Thomas
Thank you for your letter and accompanying report, which the Health Board received on 23 October
2024.
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 Jean Thomas.
As requested, the information presented below is intended to describe the actions which have been
taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future deaths.
You required the Heath Board to provide you with the following information.
Reassurance that fluid balance is monitored by the nursing and medical staff, and the
response must contain details of action taken and proposed to be taken, setting out the
timetable for actions.
Firstly, the Health Board would like to provide assurance that it is committed to improving what is
basic but vital monitoring documentation to prevent deterioration and to monitor patients’ health
needs. The Health Board has a commitment to improved compliance, which is demonstrated
through our ward accreditation process where fluid balance performance forms part of multiple
audits including daily, weekly, and monthly monitoring. We aim to enhance education through the
Cross Divisional Task and Finish Group and adopt a multi-disciplinary approach to the use of fluid
balance monitoring to improve patient outcomes and prevent avoidable harm.
Following the raising of the matters of concern, it is recognised that additional training and education
is required to ensure that staff are clear on their responsibilities and the importance of using the fluid
balance tool to prevent patient harm.
The action plan the Health Board has developed will enable the improvement of monitoring of patient
fluid balance across the organisation, improve management of patient’s fluid balance by the multi-
disciplinary team, and provide assurance on the review of quality and compliance of fluid balance
monitoring as an ongoing quality indicator.
Bwrdd Iechyd Prifysgol Aneurin Bevan
Pencadlys, Ysbyty Sant Cadog
Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ
01633 436 700
BwrddIechydPrifysgol
BIPAneurinBevan
Rydym yn croesawu gohebiaeth yn Gymraeg a byddwn yn ymateb yn Gymraeg heb oedi.
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan.
Aneurin Bevan University Health Board
Headquarters, St Cadoc’s Hospital
Lodge Road, Caerleon, Newport NP18 3XQ
01633 436 700
AneurinBevanHealthBoard
AneurinBevanUHB
We welcome correspondence in Welsh and we will respond in Welsh without delay.
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board.
A review of current Health Board documentation and monitoring tools across the Region, alongside
a review of recommended National Guidelines has taken place to provide the evidence base that
will lead to best practice.
Learning implemented to date and future plans:
A pilot project on fluid balance monitoring will be initiated on a surgical ward, incorporating
education, information boards, and sharing and auditing of data. The pilot will evolve into a broader
implementation project once the PDSA improvement tools demonstrate progress in the pilot area.
A Health Board Multidisciplinary Fluid Balance Task & Finish Group has formed with key objectives
set which include:
(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4)
Increase awareness about the expected standards for fluid balance monitoring across the
Health Board through various communication methods, such as feedback sessions, posters,
emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
Identification and delivery of the multidisciplinary training requirements to ensure sustainable
improvement in fluid balance monitoring.
(5)
Education programs will be strengthened to support multidisciplinary team members understanding
of their roles and responsibilities in managing patient fluid balance, in accordance with NICE
guidelines. The programme will equip staff with the knowledge required to ensure best practice.
Compliance with fluid balance monitoring and subsequent improvements will be incorporated into
the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically
to support education and establish clinical expectations. Learning from Medical Examiner feedback
and the Quality Safety Learning Forum will be incorporated into the improvement plan.
The AMAT tool will be used to standardise the audit process for fluid balance compliance across
the health board. Audits will be carried out in accordance with the Ward / Team Accreditation
process and will be reported to the Nutrition & Hydration Committee.
Fluid balance monitoring will be added to the Nutrition and Hydration Committee risk register and
will be kept under review until improvements in standards are consistently achieved.
I would like to personally assure you that there is Health Board wide multidisciplinary commitment
to ensuring improved standards are met and sustained in relation to fluid balance monitoring. I trust
this information and the enclosed detailed action plan provides the necessary reassurance regarding
the matters raised. Should further clarification or additional assurance be required, please do not
hesitate to contact me.
Yours sincerely
Prif Weithredwr | Chief Executive
Enc. Action Plan
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