Mark Sumnall

Coroner's concerns

AI summary

The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital staff are unaware of its purpose, leading to critical care plans not being accessed.

View full coroner's concerns

The Derbyshire wide Red Bag scheme is an initiative designed to ensure that when care home residents are admitted to hospital, key health and social care information travels with them by way of documentation such as care plans (as well as medication and essential personal items). I understand that the County Council and the CCG are the primary agencies responsible for the scheme. On the evidence considered at Mr Sumnall’s inquest:
1. The scheme does not appear to be widely used in Derbyshire, although the scheme was in response to NICE guidance for improving patient care and safety when transferring between health and care settings (NG27: Transition between inpatient hospital setting and community or care homes). The inquest heard that Mr Sumnall’s care home only had one bag for use on the premises, and that ambulance and hospital staff did not routinely deal with admissions where care home patients were sent with Red Bags.
2. The Red Bag travelled with Mr Sumnall and was found with his clothes when he died. Despite being with him there is no evidence that anyone looked in the bag to check for relevant information. This being the case it appears to me that there is lack of awareness of how the bag should be used, but also, as no enquires were separately made for care plan and other relevant documentation, that the thrust of the NICE guidance for improving patient care and safety is not being addressed systematically between agencies.

Responses

2 respondents

NHS Derby and Derbyshire Integrated Care Board

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Action Taken

NHS Derby and Derbyshire has distributed updated 'Red Bag' documentation and communications to care homes, ambulance, and hospital trusts, and held meetings with Deputy Directors of Nursing to ensure effective handover communications. They will also implement an interim transfer document by September 2022 and monitor its use. (AI summary)

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Dear Mr Nieto,

Thank you for your letter dated 30th May 2022 to the former organisation, NHS Derby & Derbyshire Clinical Commissioning Group (CCG), which included the Regulation 28 report regarding the death of Mr Mark Edwin Sumnall. This response has been created under the auspices of the successor organisation, NHS Derby & Derbysire Integrated Care Board (ICB) established on the 1st of July 2022.

We have had now had the opportunity to review the concerns you have identified following your investigation into the death of Mr Sumnall.

The Derbyshire Care Home Red Bag scheme was launched in 2018 with the intention that the integrated pathway would support care homes, ambulance services and hospitals to meet the requirements of NICE guideline NG27: Transition between inpatient hospital setting and community or care homes.

The red bag is a convenient and portable way of ensuring that all the necessary documents and personal items accompany the care home resident and follows them from admission, during their hospital stay, and then following discharge, back to the care home. The red bag is easily identifiable and designed to hold all the essential belongings and standardised documents that care home and hospital staff need when a patient is admitted to hospital.

Our investigation has identified that, although strong leads and champions were in place at the outset when the scheme was launched, there has not been sustained leadership and ongoing system commitment to the scheme. The fixed term nature of the funding of the quality improvement did not adequately cover for long term sustainability. Continued input from project staff was required to regularly contact hospitals to locate missing bags and to maintain communication and raise awareness among other relevant and new staff. This means a sustained focus on the continuation of and ongoing system engagement with this pathway has not been consistently in place.

The following actions have been put in place as a result of the review of the concerns raised in the investigation:

Chair:

Chief Executive:

Head office address: 1st Floor North, Cardinal Square, 10 Nottingham Road, Derby, DE1 3QT
• The CCG did meet with our Local Authority colleagues to discuss the Regulation 28 report and actions that need to be taken to prevent future deaths associated with urgent transfer from care homes to hospital.
• We agreed at the system Integrated Care Homes Steering Group on 22nd June 2022 that actions required will be reported through and monitored by the Integrated Care Homes Steering Group. Leads were identified from the Local Authority and CCG / ICB.
• The Joint Leads met on Friday 24th June 2022 and agreed to:

 Distribute urgent communications to care homes, refreshing previous guidance issued when the Red Bag Pathway was first introduced. This will include guidance on formal communication and handover requirements when transferring a resident to hospital where they do not have a red bag. This was had been completed.

 Distribute urgent communications to the Ambulance Trust and Hospital Trusts refreshing previous guidance regarding red bags. This will reiterate that there are still a number of red bags in the system, they need to ensure all staff are aware of the contents of the red bag and investigate the contents as they include crucial information regarding the patient and any associated risks. This communication has been sent.

 Meet with the Deputy Directors of Nursing from both Hospital Trusts to agree internal action each will take to ensure effective and robust handover communications when receiving patients into the hospital both in the emergency department and wards. These meetings have taken place.

 Implement an interim care home to hospital and hospital to care home transfer document. Full roll out will be by the end of September 2022.

 Monitor of the use of the care home to hospital transfer documentation, this will be incorporated into the routine quality monitoring undertaken by the Local Authority and the ICB Care Home Quality Team. This will be put in place once the interim arrangements are rolled out.

 Review the urgent transfer from care home to hospital information standard and link with the local NHS and LA digital transformation leads to expedite ICS wide initiatives to implement the new digital standards. The link with Digital workstream 'Digital Social Care Records' has been established.

I sincerely hope that this provides you with the assurance that as an ICB (previous CCG) and as a system we are taking appropriate actions to prevent avoidable deaths of this nature where robust communication at all stages between organisations would have made a difference.

Derbyshire County Council Local Authority / Fire Service

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Action Planned

Derbyshire County Council is developing an action plan to improve information transfer from care homes to hospitals, including implementing an interim transfer document by September 2022 and reviewing digital transfer standards by August 2022, aiming for 80% digital social care records by March 2024. (AI summary)

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Dear Sir Thank you for your letter dated 30th May 2022, which included the Regulation 28 report regarding the death of Mark Edwin Sumnall. Derbyshire County Council’s Adult Social Care department has now had the opportunity to review the concerns you have identified following your investigation into the death of Mark Edwin Sumnall and to work with partners across the health and social care system to develop an appropriate action plan in response to this. The Derbyshire Care Home Red Bag scheme was launched in 2018 with the intention that the integrated pathway would enable care homes, ambulance services and hospitals to meet the requirements of NICE guideline NG27: Transition between inpatient hospital setting and community or care homes. The red bag is clearly identifiable and is a convenient, and transportable way of ensuring that all the necessary documents and personal items of the care home resident follow them from their care home to hospital, during their hospital stay, and following discharge, back to their care home. It is designed to hold all the essential belongings and standardised documentation that care home and hospital staff need when an individual is admitted to hospital and was implemented as a quality assurance mechanism. Our investigation has identified that there has not been sustained leadership and ongoing system commitment to the scheme despite strong leadership, as well as scheme champions, during the launch and early phases of the scheme. The funding for the scheme was for a fixed term and enabled the initial launch as well as a small stock of red bags to be available to replace any that had been lost during the first few years of the scheme; however, it did not facilitate sustainability of the scheme. As with any quality assurance mechanism, the scheme required continued action to ensure it was effective and this included: project staff time to continue to raise awareness of the scheme via induction training and regular communication with all agencies involved as well as quality monitoring work to ensure the scheme was working effectively and any quality improvement work required was acted upon. The Email:

Date: 21st July 2022 Our Ref: GP Mr Peter Nieto Area Coroner for Derby & Derbyshire, Derby Coroner’s Court, St Katherine’s House St Mary’s Wharf, Mansfield Road, Derby, DE1 3TQ

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effectiveness of the scheme relied upon multi-agency workers knowing of the scheme and ensuring that they implemented it for each admission to hospital from a care home. Our investigation has highlighted that there has not been consistent leadership of the scheme across our system.

As a result of the regulation 28 report, Derbyshire County Council’s Adult Social Care department has taken the following action:

• Met with our colleagues in the Clinical Commissioning Group (CCG) to discuss the Regulation 28 report and actions that need to be taken to prevent future deaths associated with urgent transfer from care homes to hospital
• We have discussed this matter at our system Integrated Care Homes Steering Group on the 22nd June 2022 and agreed as a local system that actions required will be reported to and monitored by the Integrated Care Homes Steering Group. Leads for this work have been identified in Adult Social Care and in the CCG.
• Those leads met on the 24th June 2022 and agreed the following actions:
1. Develop, approve and disseminate urgent communications to care homes asking them to utilise red bags where they have them. Review previous guidance on the scheme and revise and develop guidance on formal communication and handover requirements when transferring a resident to hospital where they do not have a red bag. The timescale for completion of this was by the end of July 2022 and it has been completed.
2. Revise, approve and distribute urgent communications to ambulance trust and hospital trusts previous guidance regarding red bags. Include that a number of red bags continue to be used across Derbyshire, that we are reviewing long term sustainability and ensure all staff members are aware of the contents of the red bag and the importance of them checking the contents as they include crucial information regarding individuals’ needs and any associated risks. The timescale for completion was by the end of July 2022 – and this has been completed.
3. For the CCG lead to meet with the Deputy Directors of Nursing from both Acute Trusts to agree the internal actions each will take to ensure effective and robust handover communications when receiving patients into the hospital in both the emergency department and on assessment and treatment wards. This will include investigation of the contents of red bags when they are used by care homes. The timescale for completion of this was by the end of July 2022 and this has been completed.
4. Review the sustainability of the red bag pathway including consideration of the risks associated with it and opportunities to implement a sustainable approach across the whole of the County footprint. Implement an interim transfer document for use when transferring individuals from care homes to hospital and hospital to care homes pending the digital solution being implemented. The timescale for full roll-out of this across Derbyshire is by the end of September 2022.

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5. Review the Urgent transfer from care home to hospital information standard and link with the local NHS and Local Authority digital transformation leads to expedite an Integrated Care System-wide initiative to implement the new digital standards. This would enable care homes to digitise and transfer individuals’ records electronically to hospital containing all relevant information. The timeframe for the discussion with local NHS and Local Authority digital transformation leads is the end of August 2022. By March 2024, 80% of adult social care providers registered with the Care Quality Commission will have digital social care records, with progress well underway for the remaining 20% by that date.
6. For effective quality monitoring and assurance mechanisms to be implemented and delivered across care home provision, ambulance and hospital trusts to monitor compliance and impact of the above actions and taking corrective action where indicated. For performance to be reported to the integrated Care Homes Steering Group for monitoring and multi-agency action. The timescale for implementation of this is from August 2022 on an ongoing basis.

I trust that this provides you with the assurance that we are taking all appropriate actions to prevent avoidable deaths of this nature in Derbyshire County Council’s Adult Social Care department and across the health and social care system where robust communication at all stages between organisations would have made a difference.

Report sections

Investigation and inquest

On 30 December 2020 I commenced an investigation into the death of Mark Edwin SUMNALL aged 64. The investigation concluded at the end of the inquest on 14 April 2022. The conclusion of the inquest was that: Mark Sumnall, known as Mark, died in hospital, on the morning of 21 December 2020, due to choking and aspirating on a sandwich given to him by hospital staff. Mark had been taken to the hospital by ambulance the previous afternoon as he appeared physically unwell and was acting out of character. Mark was diagnosed with chronic schizophrenia, and chorea movement disorder. He had a recognised choking risk due to rushing his food and his food had to be appropriately cut up and Mark was supervised whilst eating. When Mark was taken to hospital by ambulance on 20 December 2020 the care home sent Mark's medication and care plan, which contained details of the choking risk, with him in a 'red bag'. The 'red bag' is a specific bag, of a holdall size, issued under a countywide scheme to highlight and transfer key documents relating to health and care when people are taken from community settings to hospital. On the evidence the hospital staff were not aware of Mark's choking risk, despite his care plan being with him in the 'red bag' at the hospital. On the evidence Mark would not have died if hospital staff had been aware of that risk because he would have been given appropriate food under supervision. The hospital staff were not aware because:
1. The presence of the 'red bag' was not highlighted to hospital staff by the member of the ambulance service who handed mark over.
2. Choking risk was not recorded on the emergency department handover record when Mark was handed over by the ambulance staff.
3. The contents of the 'red bag' was not investigated by hospital staff prior to Mark's death.
4. A telephone conversation between an emergency department doctor and a member of the care home staff did not explore Mark's needs and risks.
5. The ambulance service patient attendance document was not reviewed by hospital staff.
6. The hospital electronic data systems at the time did not permit the hospital staff to access Mark's previous hospital records which contained information of his choking risk.

Circumstances of the death

The circumstances are detailed above in section 3 of this report. The medical cause of death, confirmed at inquest, was: 1(a) Food inhalation 2 Schizophrenia, coronary atherosclerosis

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Royal Derby HospitalAspen House Care HomeEast Midlands Ambulance Service

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