Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0190, written 15 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2025 |
|---|---|
| Reference | 2025-0190 |
| Deceased | Samuel Brookes |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford & Wrekin |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Dudley Group NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Russells Hall Hospital Dudley West Midlands DY1 2HQ Telephone: 01384 456111 Date: 29 May 2025 Private and Confidential Mr John Ellery H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8H Dear Mr Ellery Re: Response to Regulation 28 Report to Prevent Future Deaths – The late Mr Samuel Joseph Brookes I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the Inquest, and your ruling on 15 April 2025 in respect of the late Mr Samuel Joseph Brookes. I would like to extend again the deepest condolences of the Trust to Mr Brookes’ family. Please be assured the significant communication and safety concerns raised as part of this inquest have been taken most seriously by the Trust. Matters of concern: 1. The hospital arranged for the late Mr Brookes’ transportation home without evidence of rearranging the required care. 2. There was no record, documentation or process to show or demonstrate that the care had been rearranged. 3. The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of the late Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. 4. The late Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly, when the late Mr Brookes got into difficulty, he could not raise the alarm or call for help. In response to the above matters of concern, an immediate cross divisional and multidisciplinary team approach has been taken to devise a robust improvement plan. Many of the actions have been implemented immediately with the remaining actions progressing within agreed timeframes. A copy of the improvement plan is enclosed below; this includes the target dates for completion, the responsible action owners, progress made to date and assurances on the effectiveness of actions taken where available. Some of the actions identified regarding patient transport, fall out of scope of the Trust. These will be taken forward by our Deputy Chief Operating Officer and Head of Site Operations and discussed with relevant integrated care system partners in relation to contractual obligations for ensuring patients discharged home are safe and have access to the agreed methods of communication e.g. mobile telephone, pendant alarm (should they have or require one). In addition to our improvement plan, the Trust has re-established with a renewed and enhanced focus the Discharge Improvement Group. This Group has strategic organisational objectives focussed not only on increasing the timeliness of patient discharges from the organisation, but more importantly on ensuring that each discharge is carried out with the highest standards of safety and quality. As part of this work, dedicated workstreams have been initiated to support the proactive and coordinated planning of discharges across both simple and complex care pathways. The group have reviewed and agreed clear outcome measures to ensure the impact of actions can be measured, and that they are having a positive impact. Metrics to monitor safe discharge will include readmission rates, patient and carer satisfaction scores, the percentage of patients returning to their original place of residence, safeguarding concerns and the number of failed / incomplete discharges. In parallel, a thematic review of historical discharge-related incidents is underway to identify key learning points and inform future priorities. The Group comprises of multidisciplinary representation, including colleagues from within the acute trust, our health and social care partners, the local authority, and a representative from our patient community. This collaborative approach is intended to provide confidence that discharge processes are being strengthened system-wide, with patient safety and continuity of care as central principles. I trust this information and enclosed action plan, provide assurances to you that the Trust has taken appropriate actions to mitigate any further patient safety issues regarding discharge and commencement of packages of care. I beg to remain sir your loyal and obedient servant. Group Chief Executive Enc. THE DUDLEY GROUP NHS FOUNDATION TRUST IMPROVEMENT PLAN Source of Improvement Plan Improvement plan prepared and lead by Regulation 28 Report to Prevent Future Deaths. – Interim Divisional Chief Nurse, , Interim Deputy Divisional Chief Nurse Lead Chief of Medicine , Discharge Team , Head of Flow and Oversight Committee Quality Committee Improvement plan signed off by Executive Lead – Chief Nurse, , Chief Operating Officer, Director , Medical Improvement Plan Agreed Capacity 27th May 2025 Anticipated date for completion July 2025 KEY Completed and Assurance Received Action commenced but not yet completed Action Overdue not completed in agreed time scales or at significant risk of note achieving time scales Assurance received Action Number 1 Recommendation / Area for Improvement Identified Disseminate the safety critical learning from the inquest findings highlighting to staff the key requirements of a safe and effective discharge. Action Agreed Lead Patient safety bulletin detailing the requirements of a safe and effective discharge to be compiled and submitted for publication across the Trust. Matron and Chief Nurse for Medicine Date for Completion 01/05/2025 Progress / Assurance y e K Patient Safety Bulletin developed and submitted for publication 29/04/2025 Patient Safety Bulletin to be disseminated across the organisation Communication Team 01/05/2025 Patient Safety Bulletin disseminated Trust wide 07/05/2025 from Communication Team Reg28May25 Action Number Recommendation / Area for Improvement Identified Action Agreed Incident learning and key requirements of safe discharge to be shared with divisional teams to ensure learning is shared widely to prevent similar incidents occurring in the future. Lead Matrons Lead Nurses Chief of Medicine Date for Completion 01/05/2025 Progress / Assurance y e K Information shared via email with lead nurses and Matrons cross divisionally including front line staff to disseminate learning to the wider teams Learning shared with Discharge Team Findings from the Regulation 28 report to prevent future deaths and learning plan to be shared at the Trust Discharge Improvement Group for organisational oversight once approved at quality committee. Matron Elderly Care Discharge Team Lead Regulation 28 report to Prevention of Future Deaths outcome and learning plan to be shared with medical staff across the divisions ensuring clinical colleagues Chief of Medicine 01/06/2025 Shared with Group 14/5/2025 21/05/2025 14/5/25 shared with clinical colleagues via email Discharge facilitators to be allocated to specific ward areas, with shared space to be utilised for all staff. Discharge Team Lead 01/05/2025 C3/FMNU, C8, AMU, C1 all allocated ward- based discharge facilitators who cross cover all areas in Medicine Division. Communication to be sent to all relevant staff disseminating the immediate requirement to fully complete the discharge checklist for all patients discharged from an inpatient bed Matron and Lead Nurses 01/05/25 Formal email sent to all leads and Matrons re completion of checklist in medicine. 2 3 Discharge team to be ward based to support more effective communication between the teams. To mandate and monitor the completion of the discharge checklist across the Trust Reg28May25 Action Number Recommendation / Area for Improvement Identified Action Agreed Lead Request for immediate Power Bi report to be built to evidence daily discharges checklist completion for monitoring Interim Divisional Chief Nurse Medicine Date for Completion 25/05/2025 Progress / Assurance y e K Power BI report designed and live. Communication sent to leads regarding responsibilities. Power BI report outputs to be overseen by the Discharge Improvement Group. Identify and inform staff of their responsibilities to monitor and action the BI reports Audits to be added to AMAT system (Trust Audit and Management Tracking System) to monitor compliance with the completion of all discharge checklists. For lead nurses to complete audits with divisional oversight. Audits are to continue with outcomes to be fed into trust Discharge Improvement Group. Corporate Quality lead 01/06/2025 Interim Deputy Divisional Chief Nurse Interim assurance measures whilst actions progress: Spot check audit completed w/c 28/04/2025 evidenced improved compliance with completion of checklists within ward areas. Divisional Chief Nurse auditing the compliance of completion Surgery. Discussed in matrons meeting on the 17/4/25 and 24/4/25 in Medicine Division – informed on the spot check audit requirements and the reporting of this. Made aware of plans additions to the AMAT system for long term audit completion. Discharge audit added to AMAT commenced 01/05/2025 Reg28May25 Action Number 4 Recommendation / Area for Improvement Identified When discharging patients, transport company to be made aware when the patient has pendant alarm and that this must be left within reach when leaving the property Action Agreed Lead Urgent communication to be sent to all transport services to share learning from the Regulation 28 and the requirement to ensure pendant alarm is within reach. Trust Lead for Capacity Date for Completion 10/05/2025 Progress / Assurance y e K Trust Lead for Capacity has communicated request to trust patient transport system private provider Cartello and driving miss daisy transport. Non-emergency transport (NEPT) meeting held 13/05/2025, support sought regarding communication with EMED, Worcester, escalation lead contact details to be sent to Lead for Capacity. Efficiency group set up across Black Country where governance and incidents will be shared going forward. Review of current contracts held with system partners and outside providers to ensure actions agreed within Trust can be met through contractual arrangements. Trust Lead for Capacity Deputy Chief Operating Officer 15/06/2025 Reg28May25 Action Number Recommendation / Area for Improvement Identified Action Agreed Lead Date for Completion 02/05/2025 Progress / Assurance y e K Spot check completed within Medicine Division on 29/04/2025; positive assurance gained that checklists are being completed, printed and sent with patients. Email sent to all leads and Matrons and DCN/DDCN. Interim Divisional Chief Nurse - Medicine Interim Deputy Divisional Chief Nurse - Medicine Associate Director Discharge 30/06/2025 14/5/25 process has commenced aiming for completion in June 2025. Communication to be sent out to all matrons and teams detailing that the nurse discharge checklist is to be printed and handed to transport company and sent with the discharged patient on discharge. Communication to detail that the discharge checklist must include key patient safety details, pendant alarm information, mobility status and to utilise the free text box with any other important information for the transferring crew (to include availability of mobile phone). This communication should include the necessary checks to be completed by transferring crews to ensure patients have necessary equipment in reach to make emergency calls/have access to pendant alarms. Within 8 weeks a Transfer of Care Hub to be set up. This is a national recommendation which brings together under one roof system partners in Dudley to improve discharge for complex patients, through colocation of intermediate care, local authority and complex discharge team in trust: it is expected that working together will streamline our processes and outcomes for the patients and their families. To improve communication between all relevant services including acute, primary care, community services, social care, housing and voluntary to coordinate care and support for patients during and following discharge process to support and Reg28May25 Action Number Recommendation / Area for Improvement Identified prevent unnecessary readmissions Action Agreed Regular feedback and updates to be provided to Discharge Improvement Group via the Care Transfer Hub workstream, which will feed up to Quality Committee for board oversight. Lead Associate Director of Discharge Date for Completion 30/06/2025 Progress / Assurance y e K Reg28May25 Draft written Discharge planning SOP written by 15/5/25 SOP out for consultation 31/5/25 Ratification 15/6/25 5 Discharge team to review and up-date the discharge planning Standard operating procedure (SOP) (previously Complex Discharge Operational Policy) to specific requirements of safe discharge. To include how to manage different pathway discharges safely and to ensure there is a process in place for when discharges fail on planned day of discharge. Process will detail escalation steps when contact with relevant parties cannot be made. Reg28May25 To review and up-date the discharge planning SOP ensuring widespread consultation when developed. Discharge team lead To ensure that the following process is included: In hours discharge facilitator to call care agency to inform them when patient will be discharged and confirm package of care to commence. This should be documented on sunrise to include care agency name, contact number and member of care agency staff communicated with Out of hours, ward staff to contact care agency on the number provided by Discharge team, to inform them of the failed discharge. Attempts of contact to be documented on sunrise. Inform site team if unsuccessful in attempts to speak with agency. At the next opportunity within hours, discharge team to contact care agency to confirm when package of care will start and document on sunrise with name of care agency and staff member communicated with. To share SOP with teams for comment to ensure the following is addressed • Out of hours protocol • Who to contact and when • When no response from care agency what is the next point of communication/escalation Action Agreed SOP to be shared at Specialty Governance meetings and for minutes to be shared with the team Lead Matrons and Lead nurses Date for Completion 01/07/2025 Progress / Assurance y e K Request made to produce a crib sheet for all staff in regard to accessing SOPs through Microsoft Share point. This has been actioned to matrons leads and directorate managers on the 14/5/25. Action Number 6 Recommendation / Area for Improvement Identified To ensure that above procedures are shared with the wider team, understood and embedded into practice. 7 Improve discharge team documentation in clinical record to evidence safe discharge Reg28May25 New SOPs and guidance to be shared trust wide. Matron and Divisional Chief Nurses to undertake in hours and out of hour ward visits to speak with staff and assess their knowledge on the safe discharge SOPs. Education and guidance to be made available on each ward on how to search and access this information Urgent meetings to be held with all discharge team staff to highlight the importance of accurate and clear documentation on all patient / care contacts. Sharing good examples and expectations in terms of communication with providers of care and next of kin/families Routine spot check audits to be scheduled and undertaken by Directorate Manager to ensure documentation requirement is evidenced in the clinical record and provide assurance action acknowledged Discharge Team Lead 01/06/2025 Divisional Director of Operations (CCCS) Discharge Team Lead 01/06/2025 Divisional Director of Operations (CCCS) Conversations held with Discharge Team to highlight documentation to include care agency details, company name and phone number. Discharge facilitator to document for every planned discharge; Care agency company name, name of staff member spoken to at the care agency, written confirmation of start date and time of package of care. Team meeting held 26/5/2025 Audit is on AMAT, has been completed for April and results shared with the team. Handed back to Service Leads and will be undertaken monthly moving forward Action Number 8 Recommendation / Area for Improvement Identified Teach and model to staff what a good discharge looks like. Action Agreed Lead Lead Nurses and Matrons across Medicine Division Jenny Bree, Corporate Lead for Improvement Reset week to be held w/c 12/5/25 across Medicine Division to reinforce processes, and incidents. This will involve testing of the improvements set out in the improvement plan, and ensure ongoing oversight and monitoring through AMAT (Trust audit system) of the discharge checklist process and feed back up to the quality working group Date for Completion 15/06/2025 Progress / Assurance Reset week took place 12/05/2025 y e K AMAT audit commenced of discharge checklist 1/5/25 Reg28May25 Action Number Recommendation / Area for Improvement Identified Action Agreed Lead Date for Completion Progress / Assurance y e K Discharge improvement group to be re-invigorated with renewed focus and clarity with clear outcomes for each of the strategic workstreams identified. (Group to have oversight of themes identified through the PSIIRF process) Deputy COO, 15/5/25 Director of Operations 14/5/25 The Discharge Improvement Group has been re-established with a renewed and enhanced focus—not only on increasing the timeliness of patient discharges from the organisation, but also on ensuring that each discharge is carried out with the highest standards of safety and quality. As part of this work, dedicated workstreams have been initiated to support the proactive and coordinated planning of discharges across both simple and complex care pathways. In parallel, a thematic review of historical discharge-related incidents is underway to identify key learning points and inform future priorities. The Group comprises multidisciplinary representation, including colleagues from within the acute trust, our health and social care partners, the local authority, and a representative from our patient community. This collaborative approach is intended to provide assurance that discharge processes are being strengthened system-wide, with patient safety and continuity of care as central principles. Reg28May25 Action Number 9 Recommendation / Area for Improvement Identified All staff who have safeguarding training and human factors training as part of their mandatory training requirements should meet Trust compliance targets for such training. Action Agreed Lead Ward staff training to be completed Lead PDN for the division to have oversight and ensure sessions are booked in a timely manner. Protected time to be allocated to staff for training to be completed. All staff who have this requirement as part of their mandatory training Lead PDN for medicine Date for Completion 01/06/2025 Progress / Assurance y e K Safeguarding Adults level 2 training 88.1% April 2025 Safeguarding training 90.59% - meets trust compliance target – May 2025 Human factors training compliance 84% Work ongoing 10 To consider if the introduction of human factors training for Discharge team staff may benefit in decision making To discuss with Education lead current content of human factors training and its benefits for non- clinical but patient facing staff members Education lead 01/07/2025 Bespoke training package to be designed for non-clinical staff to support with Human factors training Reg28May25
JOHN ELLERY H.M. SENIOR CORONER FOR SHROPSHIRE, TELFORD & WREKIN AREA H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HB Coroner's Office: Email: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Pensnett Road, Dudley, West Midlands, DY1 2HQ . Chief Executive, Russells Hall Hospital, Dudley Group NHS Foundation Trust, 1 CORONER I am John Ellery, H.M. Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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 3 May 2024 I commenced an investigation into the death of Samuel Joseph BROOKES The investigation concluded at the end of the inquest on 24, 25 March & 9 April 2025 The conclusion of the inquest was; The deceased died following neglect to provide him his required care. 4 CIRCUMSTANCES OF THE DEATH Mr Brookes was discharged home from Russells Hall Hospital, Dudley on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day. Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours. It is not known when Mr Brookes died between the 8 & 22 April 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 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. – (1) The hospital arranged for Mr Brookes transportation home without rearranging the required care as set out in paragraph 4 above. (2) There was no record or documentation or process to show or demonstrate that the care had been rearranged. (3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. (4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 10 June 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. FBC Manby Bowdler LLP, Solicitors representing the family 2. Weightmans LLP, Solicitors representing Dudley Group of Hospitals 3. Outcome Care and Support 4. Cartello Ambulance - Transport Company 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 John Ellery H.M. Senior Coroner Shropshire, Telford & Wrekin 15 April 2025 Send to: 3
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