Cumbria NHS
Action Taken
The trust has implemented multiple actions, including notifying the collaborative of community deaths within 30 days of elective surgery, sharing information with the Mortality Surveillance Group, providing Legal Team training to Collaborative, sharing information with relevant staff regarding anticoagulation, and sharing good practices in the physiotherapy department. Updates to the system to include VTE on discharge in the nursing checklist are planned. (AI summary)
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Coroner’s ref: Trust ref: North Cumbria Integrated Care’s Regulation 28 Updated Action Plan Concerning the Inquest into the death of Karena Wickings Dated: 01/05/2024 Concern 1 The surgical mortality conducted after Karena’s death does not seem to have considered the role that anticoagulation might have played. Recommendation 1: Lead: Action: Target Date: Update: Business Intelligence Team to notify Collaborative of community deaths within 30 days of elective surgery to allow for clear escalation and timely review of patient’s care. A documented process for action which should be taken, once a notification of coronial case is Collaborative Lead Nurse’s within Critical Care, Specialist Surgical and Surgical Care alongside the Mortality Surveillance Group as Trust wide Head of Legal Services Share the information received from Business Intelligence with the Mortality Surveillance Group and agree how case reviews will occur within the Collaborative. To provide a clear instruction to the recipients around what is required from them once April 2024 April 2024 03/04/2024 listed to be discussed at the next mortality meeting 15/04/2024 discussed at mortality meeting. Plan for the Business Intelligence Team to send monthly reports to the Surgical Collaborative Lead Nurse and this will be shared via email to all Lead Nurses and then be discussed at Directorate level. Complete. Email sent to Legal Services Team 23/04/2024:
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received from the Legal Team to intended recipients. notified of a coronial case to cross reference if the case review has already been undertaken. Training to be provided by the Legal Team to Collaborative to increase knowledge base and awareness of process. Inquest Templates SLegal Services NCIC Due to service pressures it is hoped that a programme will be delivered by the end of
2024.
Guidance is already in place and provided when requesting information from the Collaborative and witnesses, and there is intention to create a Trust specific inquest guide. Concern 2 Evidence heard that within this case Trust and NICE guidance was followed, but no evidence of consideration to extending the VTE prophylaxis on discharge Recommendation 2: Lead: Action: Target Date: Update: Update the Pharmacological VTE Prophylaxis in Adult Medical and Surgical Patients Guidelines to include advice on discharge and documenting VTE risk. Clinical Director for General Surgery and Medicine Review latest NICE guidance and update Trust Guidelines. April 2024 03/04/2024 Guideline with the Clinical Director for General Surgery and is currently being updated. Recommendation 3: Lead: Action: Target Date: Update: Amend the nursing discharge checklist to document the ongoing plan for VTE prophylaxis at the time of discharge, to ensure patient Matron Share Regulation 28 with all Matrons for awareness. April 2024 Email sent to Matrons 03/04/2024:
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information advice and management plan if for pharmacological VTE. Liaise with Digital Systems to update the system to include VTE on discharge in the nursing checklist. Audit discharge checklist to ensure compliance with checklist. Regulation 28 sharing with CLN.ms 03/04/2024 Meeting with held with Chief Nursing Information Officer to discuss implementation. Recommendation 4: Lead: Action: Target Date: Update: VTE assessment at the time of discharge to be documented on the electronic discharge summary, providing an update on actions taken to reduce this risk and any further actions required. Surgical Care Collaborative Chair Provide training and guidance around the assessing and documentation of VTE at time of discharge. Amend discharge summary. Describe clear plan of ownership should a patient be discharged on pharmacological VTE. To be reviewed in line with Medical Discharge Summary Improvement Project. June 2024
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Recommendation 5: Lead: Action: Target Date: Update: Amend the ward round proforma to include daily review of VTE in place and plan for discharge with regards to VTE. Surgical Care Collaborative Lead Nurse Discuss with surgical speciality the ward round proforma and understand how best to prompt for a daily VTE review and also a clear plan for discharge around VTE risk. April 2024 03/04/2024 Draft version completed but awaiting final sign off on new clinical guideline to ensure all information is captured. Concern 3 Karena was experiencing significantly reduced mobility at the time of discharge. Recommendation 6: Lead: Action: Target Date: Update: Appropriate action taken around reduced mobility from the physiotherapy team to support ongoing rehabilitation. Head of Physiotherapy To share good practice within department. February 2024 Completed 03/04/2024 as confirmed via email: confirmation of sharing with AHP.ms
Coroner’s ref: Trust ref: North Cumbria Integrated Care’s Regulation 28 Updated Action Plan Concerning the Inquest into the death of Karena Wickings Dated: 01/05/2024 Concern 1 The surgical mortality conducted after Karena’s death does not seem to have considered the role that anticoagulation might have played. Recommendation 1: Lead: Action: Target Date: Update: Business Intelligence Team to notify Collaborative of community deaths within 30 days of elective surgery to allow for clear escalation and timely review of patient’s care. A documented process for action which should be taken, once a notification of coronial case is Collaborative Lead Nurse’s within Critical Care, Specialist Surgical and Surgical Care alongside the Mortality Surveillance Group as Trust wide Head of Legal Services Share the information received from Business Intelligence with the Mortality Surveillance Group and agree how case reviews will occur within the Collaborative. To provide a clear instruction to the recipients around what is required from them once April 2024 April 2024 03/04/2024 listed to be discussed at the next mortality meeting 15/04/2024 discussed at mortality meeting. Plan for the Business Intelligence Team to send monthly reports to the Surgical Collaborative Lead Nurse and this will be shared via email to all Lead Nurses and then be discussed at Directorate level. Complete. Email sent to Legal Services Team 23/04/2024:
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received from the Legal Team to intended recipients. notified of a coronial case to cross reference if the case review has already been undertaken. Training to be provided by the Legal Team to Collaborative to increase knowledge base and awareness of process. Inquest Templates SLegal Services NCIC Due to service pressures it is hoped that a programme will be delivered by the end of
2024.
Guidance is already in place and provided when requesting information from the Collaborative and witnesses, and there is intention to create a Trust specific inquest guide. Concern 2 Evidence heard that within this case Trust and NICE guidance was followed, but no evidence of consideration to extending the VTE prophylaxis on discharge Recommendation 2: Lead: Action: Target Date: Update: Update the Pharmacological VTE Prophylaxis in Adult Medical and Surgical Patients Guidelines to include advice on discharge and documenting VTE risk. Clinical Director for General Surgery and Medicine Review latest NICE guidance and update Trust Guidelines. April 2024 03/04/2024 Guideline with the Clinical Director for General Surgery and is currently being updated. Recommendation 3: Lead: Action: Target Date: Update: Amend the nursing discharge checklist to document the ongoing plan for VTE prophylaxis at the time of discharge, to ensure patient Matron Share Regulation 28 with all Matrons for awareness. April 2024 Email sent to Matrons 03/04/2024:
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information advice and management plan if for pharmacological VTE. Liaise with Digital Systems to update the system to include VTE on discharge in the nursing checklist. Audit discharge checklist to ensure compliance with checklist. Regulation 28 sharing with CLN.ms 03/04/2024 Meeting with held with Chief Nursing Information Officer to discuss implementation. Recommendation 4: Lead: Action: Target Date: Update: VTE assessment at the time of discharge to be documented on the electronic discharge summary, providing an update on actions taken to reduce this risk and any further actions required. Surgical Care Collaborative Chair Provide training and guidance around the assessing and documentation of VTE at time of discharge. Amend discharge summary. Describe clear plan of ownership should a patient be discharged on pharmacological VTE. To be reviewed in line with Medical Discharge Summary Improvement Project. June 2024
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Recommendation 5: Lead: Action: Target Date: Update: Amend the ward round proforma to include daily review of VTE in place and plan for discharge with regards to VTE. Surgical Care Collaborative Lead Nurse Discuss with surgical speciality the ward round proforma and understand how best to prompt for a daily VTE review and also a clear plan for discharge around VTE risk. April 2024 03/04/2024 Draft version completed but awaiting final sign off on new clinical guideline to ensure all information is captured. Concern 3 Karena was experiencing significantly reduced mobility at the time of discharge. Recommendation 6: Lead: Action: Target Date: Update: Appropriate action taken around reduced mobility from the physiotherapy team to support ongoing rehabilitation. Head of Physiotherapy To share good practice within department. February 2024 Completed 03/04/2024 as confirmed via email: confirmation of sharing with AHP.ms