Source · Prevention of Future Deaths

Rhys Hill

Ref: 2024-0021 Date: 15 Jan 2024 Coroner: Alison Mutch Area: Manchester South Responses identified: 2 / 2 View PDF

Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.

Date 15 Jan 2024

56-day deadline 11 Mar 2024 est.

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.

View full coroner's concerns

1. The inquest heard evidence that communication between clinicians and the nursing team on the neurosurgical ward was not effective. The teams appeared to operate in silos and key information about patients did not appear to have been shared between the teams;
2. Documentation (clinical and nursing) was incomplete and did not detail key/important information about Rhys. This included ward round notes containing limited information which meant it was difficult to know what matters had been considered as part of discharge planning and what information was known to the clinicians;
3. THE VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE;
4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes;
5. The evidence was that the system and responsibility between the hospital pharmacy and clinicians for reconciling medications given in the community with those given in the hospital to ensure all necessary medications were given was unclear. As a consequence, Rhys did not receive his ADHD medication;
6. There appeared to be limited understanding amongst the nursing team of when a hospital “passport” system should be instigated for someone who was admitted with a “passport”;
7. The system for deciding when a discharge form the neuro surgical ward was safe was unclear. The evidence appeared to suggest that the Physiotherapy team took responsibility for it if they assessed mobility at a suitable level. It was unclear how that was overseen and fitted with the responsibility of the treating clinician;
8. The VTE policy of the trust is based on the NICE guidance. The inquest identified that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neuro surgical patient. Where there is a bariatric patient who is a neuro surgical patient there does not appear to be any clarity on how the challenges should be approached to reduce the risk of VTE as far as possible.

Responses

2 respondents

Lancashire Teaching Hospitals NHS / Health Body

8 Mar 2024 PDF

Action Planned

The organisation has formulated an action plan in response to the concerns raised and shared it with the deceased's family. (AI summary)

View full response

Dear Ms Mutch, RE: Inquest Rhys Lennon-Hill. Regulation 28 Report Further to your letter of the 15th January 2024 and the associated Regulation 28 report please find attached action plan formulated in response which addresses each of the concerns that you raised. Whilst I have not included the underpinning evidence, I have instead referenced this within the action plan. I would be pleased to share further updates and detail of the actions if this would assist you further. Can I offer my sincerest apologies that you had cause to issue the Regulation 28 report. I hope that our response assures you of our commitment to learn both from Rhys’s death, and from the subsequent inquest. Following the inquest, the Chief Nursing Officer and I met with to offer further apologies and to listen to her concerns. We have written to Mrs Hill to update her on progress in line with her wishes and enclosed a copy of the action plan. Please do let me know if we can be of further assistance.

NHS England NHS / Health Body

2 Apr 2024 PDF

Action Taken

NHS England highlights existing national guidance on VTE prophylaxis and medicines optimisation, and states that it engages with ICBs on concerns raised in reports. They note that all reports received are discussed by the Regulation 28 Working Group. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Rhys Lennon Hill who died on 9 February 2023. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 January 2024 concerning the death of Rhys Lennon Hill on 9 February 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Rhys’ family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Rhys’ care have been listened to and reflected upon. I apologise for the delay in responding to your Report, and for any anguish this may have caused to Rhys’ friends and family. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them. This response focuses on the issues raised in your Report within the remit of NHS England national policy and programmes. Concern numbers one to seven in your Report fall under the remit of Lancashire Teaching Hospitals NHS Foundation Trust. I note that you have also addressed your Report to the Trust, who are the appropriate organisation to respond. NHS England has requested to be sighted on this and will carefully consider their response to the coroner. My regional Quality colleagues within the North West have been engaging with Lancashire and South Cumbria Integrated Care Board (ICB) to seek assurance for the local concerns raised. Concern number eight in your report raises concerns that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neurosurgical patient. You raised the concern that where there is a bariatric patient who has also undergone neurosurgery there is a lack of clarity on how to reduce the chances of venous thromboembolism (VTE) occurring. As your Report notes, the National Institute for Health and Care Excellence (NICE) produce the relevant clinical guidelines [NG89] for reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism and the Quality Standard for Venous thromboembolism in adults [QS201]. You may also therefore wish to refer your concerns to NICE. A1

The NG89 guidelines include a section on risk assessment (section 1.1) which states the importance, in the case of surgical patients of balancing ‘the person’s individual risk of VTE against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to surgical and trauma patients.’ The NICE guidance also states that mechanical VTE prophylaxis should be offered to ‘people undergoing elective spinal surgery’ (section 1.12), comprising either anti- embolism stockings or intermittent pneumatic compression. Pharmacological VTE prophylaxis should be used ‘for people undergoing elective spinal surgery whose risk of VTE outweighs their risk of bleeding, taking into account individual patient and surgical factors (major or complex surgery) and according to clinical judgement.’ NHS England is in the process of undertaking some work to review the characteristics of individuals who get thrombosis. It is intended that this will look at the medication people are on and whether they have certain comorbidities. It is possible that the outcomes of this could influence further work around thrombosis risk factors. NICE also produce guidance on medicines optimisation [NG5] which includes a section on medicines reconciliation: 1 Recommendations | Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes | Guidance | NICE (section 1.3). As noted above, NHS England has engaged with Lancashire and South Cumbria ICB on the other concerns raised in your Report and are aware that Lancashire Teaching Hospitals undertook a Serious Incident Review into the care delivered to Rhys. We refer you to the Trust’s response, but NHS England is advised that:
• The Trust did undertake VTE assessments, prescribing both mechanical and pharmacological prophylaxis.
• There is evidence that education was provided to the patient on the importance of the medication scheduled.
• That the patient declined to wear the anti-embolic stockings prescribed.
• That the Trust have taken actions to improve holistic care and adopt learning from the care delivered to Rhys which includes a review of VTE guidance on assessment pre-discharge, VTE advice leaflet to be provided in pre-admission packs and to ensure that a Senior Nurse acts as a link from daily nurse safety huddles to the daily ward round. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. A2

Report sections

Investigation and inquest

On 9th February 2023 I commenced an investigation into the death of Rhys Lennon Hill. The investigation concluded on the 20th December 2023 and the conclusion was one of Narrative: Died from a complication of a previous surgical procedure, where the complication was not identified until after his death. The medical cause of death was 1a) Pulmonary Embolus; 1b) Deep Vein Thrombosis formation in the context of recent Primary Lumbar Discectomy

Circumstances of the death

Rhys Lennon Hill had spinal surgery at the Royal Preston Hospital. On 30th January 2023 Rhys was offered his Dalteparin. He refused it. On the balance of probabilities that refusal was linked to the time it was offered at and because he was in some discomfort. The refusal of Dalteparin was not escalated to the clinical team and there is no evidence that the risk presented by the omission of the dose of Dalteparin was evaluated by the treating clinicians. Rhys was discharged on 30th January 2023 from the Royal Preston Hospital. The Trust policy required that at discharge a patient and their family members must be provided with verbal and written information about VTE. The Trust policy was not followed. As a consequence, Rhys and his family did not have clear instructions on how to reduce the risk of developing a VTE and the symptoms to look for. This probably increased the risk of Rhys developing a VTE. On 9th February 2023 Rhys collapsed at his home address and attempts to resuscitate him were unsuccessful. A post-mortem examination found that he had died from a pulmonary embolus due to a deep vein thrombosis. On the balance of probabilities, the cause of his deep vein thrombosis was the recent surgery he had had undertaken. The risk of him developing a deep vein thrombosis was increased by the Trust discharge policy not being followed and a risk assessment not being undertaken following his refusal of the Dalteparin on the morning of the discharge. 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 inquest heard evidence that communication between clinicians and the nursing team on the neurosurgical ward was not effective. The teams appeared to operate in silos and key information about patients did not appear to have been shared between the teams;
2. Documentation (clinical and nursing) was incomplete and did not detail key/important information about Rhys. This included ward round notes containing limited information which meant it was difficult to know what matters had been considered as part of discharge planning and what information was known to the clinicians;
3. THE VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE;
4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes;
5. The evidence was that the system and responsibility between the hospital pharmacy and clinicians for reconciling medications given in the community with those given in the hospital to ensure all necessary medications were given was unclear. As a consequence, Rhys did not receive his ADHD medication;
6. There appeared to be limited understanding amongst the nursing team of when a hospital “passport” system should be instigated for someone who was admitted with a “passport”;
7. The system for deciding when a discharge form the neuro surgical ward was safe was unclear. The evidence appeared to suggest that the Physiotherapy team took responsibility for it if they assessed mobility at a suitable level. It was unclear how that was overseen and fitted with the responsibility of the treating clinician;
8. The VTE policy of the trust is based on the NICE guidance. The inquest identified that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neuro surgical patient. Where there is a bariatric patient who is a neuro surgical patient there does not appear to be any clarity on how the challenges should be approached to reduce the risk of VTE as far as possible.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0021
Date of report: 15 January 2024
Coroner: Alison Mutch
Coroner area: Manchester South

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Mar 2024 (estimated).

Sent to

Lancashire Teaching Hospitals

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.