Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0138, written 11 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2025 |
|---|---|
| Reference | 2025-0138 |
| Deceased | Allan Taylor |
| Coroner | David Place |
| Coroner area | Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South Tyneside and Sunderland 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.
David Place Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: South Tyneside and Sunderland NHS Foundation Trust 1 CORONER I am David Place, His Majesty’s Senior Coroner for the City of Sunderland 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 6th February 2025 I commenced an Investigation into the death of Mr Allan Taylor, who died in Sunderland Royal Hospital on 1st June 2024 aged 90 years. The Investigation concluded at the end of the Inquest on 5th March 2025. I gave a narrative conclusion ‘Natural causes contributed to by the physiological strain of necessary surgical procedure to a fractured neck of femur following an unwitnessed fall in hospital.’ The medical cause of death was: - Ia Myocardial Infarction Ib Hypertension Ic Chronic Kidney Disease II Frailty of Old Age, Fractured Neck of Femur (Operated) 4 CIRCUMSTANCES OF THE DEATH Allan was admitted on 28th May 2024 to Sunderland Royal Hospital following an unwitnessed fall at home with a long lie. Upon admission to hospital Allan was assessed as requiring Level 1 EICO observations, and this was upgraded to Level 2 at 19:14hrs on 29th May 2024 due to concerns around Allan’s confusion. Allan had been placed in a Side Room 1 due to concerns regarding possible clostridium difficile infection, which was later confirmed positive after tests. Allan had been assessed by a physiotherapist on 29th May 2024 that he needed minimal assistance to mobilise with the assistance of one person and a wheeled Zimmer frame. Allan had an unwitnessed fall on 29th May 2024 at 23:20hrs, with the evidence suggesting that he had moved to the end of his bed to negotiate the bed rails and then walked unaided for approximately 5 metres before falling, resulting in a fractured right neck of femur, which required necessary surgical intervention, as immobility posed a significant risk to him. Noise from his room had alerted a nurse who found him on the floor between the bed and the en-suite bathroom. On 30th May 2024 Allan was moved to an orthopaedic ward in preparation for surgery. Following an uneventful induction of anaesthesia on 1st June 2024, Allan became hypotensive on the operating table and went into a cardiac arrest. Allan passed away whilst in theatre due to the physiological strain of the surgery. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed a matter 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: – 1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it. 2. The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations. 3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall. I shall be glad to be told of any learning arising from this death and timescales and results of your review. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 this report, namely by 7th May 2025. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Page 2 of 3 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 to the following Interested Persons: - • Family • 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. 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 this 11th day of March 2025 Signature: HM Senior Coroner for the City of Sunderland Page 3 of 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.
NHS South Tyneside and Sunderland NHS Foundation Trust Chief Executive: Sunderland Royal Hospital Kayll Road Ref: Sunderland Tyne & Wear 6 May 2025 SR47TP Tek: 0191 565 6256 ext 42404 Direct tel: 0191 569 9688 PRIVATE & CONFIDENTIAL www.stsft.nhs.uk Mr D Place Senior Coroner for the City of Sunderland City Hall Plater Way SUNDERLAND SR1 3AA Qe Ny Place, Dear lace Regulation 28 Report to Prevent Future Deaths — Mr Allan Taylor ! write further to your correspondence dated 11 March 2025 regarding your concerns identified during the Inquest into Mr Taylor's death. Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns. Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other local Trusts manage safe observation and care of patients. This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months. During the Inquest, you identified a concern that there is a risk that future deaths will occur unless action is taken. The matters of concern were: 4. Guidelines for Level 2 EICO were not complied with 2. There was a lack of escalation to the Matron or Site Manager 3. Had Mr Taylor received the Level 2 EICO, assistance could have been provided to him which may have prevented his fall excellence in all that we do Following the internal investigation there has been significant learning identified which has been reflected within the actions as indicated above including clearer guidance for staff, importance of family involvement, escalation and documentation, training, and the use of professional judgement. In Mr Taylor's case, he was required to be in a side room due to testing positive for Clostridium Difficile. The allocation of a patient to a side room with infectious conditions is always a balance of risk between their individual needs and the protection of other patients in the open bay areas. The nursing staff responsible for his care did not feel, at that time, that he required EICO level 2 as he had become settled. Whilst we recognise the importance of professional judgement; given this is guidance and not policy; the staff failed to record their decision and the reasons for not escalating this further to the Matron or Site Manager. Mr Taylor was assessed to have mental capacity on admission to hospital, however two days later he fell and the staff responsible for his care believed he then lacked capacity. They followed the trust policy by completing an MCA1 and 2 and a Deprivation of Liberty Safeguard, a safeguarding referral was then made to the Local Authority. | would like to assure you that this improvement work is progressing well, and we intend to embed this ETOC guideline and will monitor the training achievements as they are introduced. As you will note, the Trust is addressing the shortfalls highlighted during the Inquest to prevent future deaths in similar circumstances. Progress of the actions detailed in this letter will be overseen by Melanie Johnson, Executive Director of Nursing, Midwifery and Allied Health Professionals, who will also keep me briefed and report progress to the Trust’s Patient Safety and Quality Committee. | trust this information provides assurance to you that the Trust has taken appropriate action to address your concerns with a view to improving patient care and safety and reducing the risk of any similar adverse incidents in the future. | would also like to take this opportunity to offer my sincere condolences to Mr Taylor's family on behalf of myself and the Trust. Yours sincerely Chief Executive
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