Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0135, written 28 Nov 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 Nov 2024 |
|---|---|
| Reference | 2025-0135 |
| Deceased | Raymond Reid |
| Coroner | Philip Spinney |
| Coroner area | Devon, Plymouth and Torbay |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT DATED 28 NOVEMBER 2024 IS BEING SENT TO:
Chief Executive – Royal Devon University Healthcare Foundation
Trust.
Family of Mr Raymond Albert Alfred Reid.
Chief Coroner.
1 CORONER
I am Philip SPINNEY, HM Senior Coroner, for the coroner area of The
County of Devon, Plymouth and Torbay.
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 9 March 2023 an investigation was commenced into the death of
Raymond Albert Alfred Reid. The investigation concluded at the end of
the inquest held on 27 November 2024. The conclusion of the inquest
was as follows:
Raymond Albert Alfred Reid died due to sepsis caused by recurrent
urinary tract infection, pressure sores and pneumonia on a background of
severe frailty.
4 CIRCUMSTANCES OF THE DEATH
On 6 January 2023 Raymond Albert Alfred Reid was admitted to North
Devon District Hospital with a catheter related urinary tract infection.
During a prolonged hospital stay Mr Reid did not respond to treatment
and developed further complications of pressure sores and pneumonia.
Despite treatment Mr Ried continued to deteriorate and sadly died in
North Devon District Hospital on 1 March 2023.
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.
1
The MATTERS OF CONCERN are as follows:
(1) Mr Reid died as a consequence of sepsis caused by a combination
of a urinary tract infection (UTI), pressure sores and pneumonia; it
was established during the evidence that it would not be possible
to determine to what extent the infection resulting from the UTI, the
pressure sores and the pneumonia individually contributed to the
cause of death.
(2) The pressure sores developed in hospital and the deterioration of
the pressure sores was possibly caused by gaps in care and
knowledge. More particularly the evidence at the inquest (and the
findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of
admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed
within 6 hours of admission and was not repeated daily in
accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21
intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not
completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved –
there were episodes during 15/2/23 to 21/2/23 when Mr
Reid was not documented to have moved for 5-10 hours.
This is not best practice.
f. Following a Tissue Viability Team assessment there was no
follow up planned – this should have been planned to
monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23.
The taking of photographs represents best practice to
enable the progress and/or deterioration of a wound to be
fully understood.
6 ACTION SHOULD BE TAKEN
I acknowledge that following the internal investigation an action plan was
developed and that the learning from this matter has extended to other
areas of North Devon District Hospital and parts of the Exeter site. The
evidence revealed that education around pressure ulcer relief is a
constant piece of work with the tissue viability team often responding
when an incident has been reported. I acknowledge that there is
evidence to support the conclusion that the work done so far since Mr
Reid’s death has resulted in a reduction in the cases of serious pressure
damage, but it is my judgement that the issues raised in this case warrant
further consideration and wider dissemination across the trust and
beyond to help improve outcomes for patients.
2
(1) Consideration should be given to reviewing the process of
Managing and treating pressure ulcers in hospital and where
necessary to provide training and education in Trust policies
and best practice to staff across the entire Trust.
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.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 4th 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
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 SIGNED:
Mr Philip C Spinney
HM Senior Coroner
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.
Email: 15 January 2025 Dear Mr Spinney North Devon District Hospital Raleigh Park Barnstaple North Devon EX31 4JB CHIEF EXECUTIVE’S OFFICE Direct Dial: Email: I am writing further to the Regulation 28 Report issued on 28 November 2024 following the inquest touching the death of Mr Raymond Reid. Mr Reid died of sepsis on a background of severe frailty. The sepsis had multiple causes but one of those was thought to be an infected pressure sore that developed while he was an inpatient in North Devon District Hospital. During the inquest, you heard evidence about the significant work that was done with the staff on Capener Ward to reduce pressure damage and that this had been successful in reducing hospital acquired pressure damage. However, you remained concerned that further work may be needed and work around pressure damage reduction may warrant further consideration and dissemination across the Trust. I am pleased to be able to write and provide you with real assurance that the Trust is doing significant work to reduce pressure damage in patients and I hope you will be reassured that this has been a priority of the Trust for some time now and substantial work is being done to ensure improvements. The RDUH Trust-wide Improvement Plan The Trust has an annually refreshed plan (the Trust-wide Improvement Plan) which is informed by scrutiny of events over the preceding year. This enables us to target our efforts on key areas of work that require ongoing quality improvement. The prevention of pressure damage has been recognised as one of these areas and continues to be one of our five main priority areas as per our Improvement plan. This issue has been on the Plan for some time, and this was refreshed in December 2024 and it remained on the plan as a top priority. This means that we have an agreed data set of identified issues and that a regular working group reviews the improvement work that has taken place to ensure we are implementing and sustaining the improvements that we have identified. Progress is reported to a Trustwide Committee (the Patient Safety Committee) with executive oversight. Further, pressure damage prevention has always been a key metric in the Trust’s integration performance framework. Data is reviewed by site and then aligned and reported and so parity of care and service delivery across both areas of the Trust has been scrutinised at Board level and the Quality Committee. Tissue Viability Steering Group In order to deliver this priority in patient care, a Trust wide Steering Group (so covering both sites in the North and East) was established in January 2024. I am attaching the minutes from the group meeting in November 2024 which also includes the Terms of Reference for the group. From this, you can see that there is a huge amount of work covered by the Group. All Care Groups attend the quarterly meeting and it is jointly led by the two Trust Tissue Viability Leads. All reported incidents of tissue damage are reviewed by the TV team in collaboration with the Care Group Senior Nurses. Immediate local learning/actions will be taken following this initial review. All incidents will also be reviewed to determine any implications for the Trust wide TV improvement plan. Trends and discrepancies in care can be identified centrally and early work can then be done to improve patient care. I am also attaching the Tissue Viability Improvement Work Plan 2024-2025. This Plan is developed, implemented and overseen by the Tissue Steering Group and is updated on a quarterly basis at the meeting. It is a comprehensive work plan setting out specific actions for improvement with accountability for completion. This Steering Group reports in to the Patient Safety Committee which includes the Directors of Nursing and Medicine as well as the Executive Chief Nursing Officer and Chief medical Officer with joint accountability for patient safety and so there is high level scrutiny of this plan and its implementation. Delivering patient care at the front line There is a huge amount of good work being done at a higher level to ensure that best practice is recommended in reducing pressure damage for patients. In order to ensure that this is actually being delivered on the front line, the Chief Nursing Officer has commissioned a significant leadership piece of work from the Director of Nursing on the Northern site. She has been asked to ensure we have right systems and processes for care in Northern services and specifically looking to “foster leadership in best practice in front line nursing staff who have ward based responsibilities regarding the day to day prevention and management of pressure ulcers”. This Group is being set up and delivery against the agreed actions will be report to the Tissue Viability Group and the Patient Safety Committee so again there will be high level and senior oversight of this piece of work. This will ensure that front line nursing leadership is able to implement the good practice and recommendations made by the Steering Group and to advance the Trust- wide Improvement Plan. I hope that the above, along with the attached documents, has given you an overview of the importance in pressure damage reduction to the Trust and how this is being delivered. Please do let me know if you have any further questions and I will be very happy to assist Yours sincerely Chief Executive Officer Chief Executive Officer: Chair:
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