Source · Prevention of Future Deaths

Sheila Steggles

Ref: 2022-0042 Date: 10 Feb 2022 Coroner: Yvonne Blake Area: Norfolk Responses identified: 1 / 1 View PDF

Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.

Date 10 Feb 2022

56-day deadline 7 Apr 2022 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Irrespective of the reason for a person’s mobility reducing, if it does so and this is a known risk factor then notice must be taken of it and appropriate steps taken. Medical staff should follow the Trust’s protocols and perform and document a VTE risk assessment when the reduction in mobility is reduced (from their baseline) even if it is not known if/ how long the reduction will continue. All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts. If a patient is to be reviewed then a specific plan should be placed on to the care plan so that everyone knows what is needed to be done. All staff should be aware of a patient’s relevant past medical history. Junior staff should consult more senior staff if they are unsure of the effect that anti coagulation will have on anti-psychotics or other medication and are thus concerned about administering this.

Responses

1 respondent

Hellesdon Hospital NHS / Health Body

22 Mar 2022 PDF

Action Taken

Hellesdon Hospital is updating the Trust induction for junior doctors to include physical health training, supported by senior consultants and underpinned by the SBAR framework. They will offer "3 Ps" training to all staff, rolling out "bite-size" training on VTE, and set up a working group for flexible working colleagues to support an education passport for health workers. (AI summary)

View full response

Dear Ma Blake wrile in respect of Shella Steggles who ded on 5" November 2019 On 10" Febquary 2022 you issucd prevention of future doaths nolice on Ihe Trust Quc t0 concerns raised dunng tne inquest which concluded on 4" February 2022 mallers 0l concein are as lollows Inespective 0l the reason for a person $ mobity reducing ( t does s0 and this Is a known risk (nator then notice must be taken 0f it and approonale steps taken Medical should lo dow the Trust $ protocols and Perform and document a VTE risk assessnieni when Ihe reduclion m mobilty is reduced (irom tneir baselire) even if It Is not known il how long Ine reduction vall continue All staft should raise concerns and Iney have specific cnes, document what Ihese are in (he clinical nolos Clinical notes should conta n more detail about tne patient 5 nce they are what Is relled upon (with verbal nandover} Io inlom stal on !arer shttts Ila eutent Is (0 D reviawred Ihen a specific plan should be placed on to tne care plon s0 thal everyone Knox& halis needed t0 Ce cone Al statt should be aNare 0fa patient $ relevant past medical history. Junior statf should consult more senior stalf if they are unsure 0l Ihe eflect Ihat anti coagulation wall nave on unli-psychotics Or other medicatian and are thus concerned about administenng this In responding to these concerns, would Ike to take this opportunily to express again Ihe Trust $ condolences her famly regarding Ihe deal of Shetla Aclions taken above (he recommendations within the internal review are primarily t0 address 'he gaps junior Doctors undarslanding and prompts {0 escalate concerns regarding physical nealth To this end tne Med cal Director tor med cal tra inees wilI be updating the Trust induction t0 include physical health Norol H eadquarets Suffolk Hcadquarters Hullaedon Hosplal Fndeavour House Drayicn High Rord; Norwich NRG 58E 8 Russell Roaj Ipawich IP2128X Tne Astati

omargancias alongside Ine existng information on psychiatric emergencies This includes being alen t0 the potential risk ol aiagnostic overshadowing This wiill be replcated within the local Inoucton und Ino Doctor handbook This reiresh includes Ihe importance of VTE assessmeni and prompt action In tespeci 0i administering propnylaxis, 75 wellJs clear guidance on when to escalate concerns based on cl nical findings The Vedical Director Ior [unior Doctors will aiso be Iaison mlh our acute hospital colleagues {0 reinstate the joint woikshops held prior (0 Ihe pandemic which shared learning and skills and promoted posiive networ n9 Handovar Delween junior Doctors and other medical staff will be underpinned by the Situation Dackground Assessmeni Recommendation (SBAR) tramewiork, ensure that patient hisfory, emerging concerns and necessary action including escalation where necessary are known; recorded and actod on , Inpaliont wards across (ne organ saton utlse a upload Ine SBAR Iool Into patient records t0 as8 5t with ward {eMietand handovers Tre SBAR document i5 Cuilt upon at each handover, (herefora bulding Up compiehensive hisiory 0f te patent All agancy and Dank stati wnlil be otered tne 3 Ps" training which covers Prevent Promole Proleci" observations and assessmeni health promobon and screaning This will be available I0 all Slall Irom support worker I0 ward manager level; tne forma: I5 a Set Of e-leaming modules accompanied by woikbook The phyaical healh Ieam are rolling out "Dite size" training across Ine trust Including Iocus o VTE and thrombolisation; In & training WIl be face I0 Iace_We nave set Up working group (o work wih our floxibla working colleaques t0 support an education passport for hea tn workers which wIIl include; acute and chronic condilions, NEWS? (deteriorating patent) managing Insuln and Use 0f protective personal equipment (infecton control measures) amongst Other subjects Tha Chiol Madical Direcior wali be spealng t0 regional colleagues about the challenges for mental healm hospital to manage serious physical healh conditions. This I5 *nth Miew (0 improving undarslanding 0f rolevani exportise and core business leacing Io improvements in communication and colaborative working hope Ihat Ihese aclions g0 some way l0 assure YOU now senously tne Trusi nas taken Ire findings 0l Irus Wrag c inc dent ard our commitment Io improve physical healn care and outcomes for QuUr pat ents Yours sinceraly eculive Nortol Headararers Sufolk Headquaners Hellesdon Hoeou Endeavour Housu Drayton Kigh Rond Nomch NRG 50E 8 Russell Road Ipswich , IF21 28X iunior This wiI

Report sections

Investigation and inquest

On 15th November 2019 I commenced an investigation into the death of Sheila Elizabeth STEGGLES aged 72. The investigation concluded at the end of the inquest on 4th February 2022. The cause of death was 1a) Acute Pulmonary Embolus (PE) 1b) Deep Vein Thrombosis (DVT) The conclusion from the jury was Natural Causes. There were a number of collective failings and missed opportunities that may have contributed to Shelia Steggles’ death.
1) There was no written Venous Thrombus Embolism (VTE) assessment for Sheila Steggles after July 2019.
2) Insufficient consideration was given to Sheila Steggles’ reduced mobility because of diagnostic overshadowing.
3) The clinical notes failed to highlight Sheila Steggles’ past medical history of Deep Vein Thrombosis (DVT) and associated risks.
4) There was inadequate DVT training for ward staff.
5) Administering a prophylactic dose of heparin may have resulted in a different outcome.

Circumstances of the death

Sheila Steggles was admitted twice under section of the Mental Health Act in 2019. She had a diagnosis of Bi-polar Affective Disorder and suffered from depression and anxiety together with Hypothyroidism and 2 previous DVT’s. She had Chronic Lymphoedema to both legs. In October 2019 Sheila Steggles was transferred to a rehabilitation ward to ready her for discharge to supported housing prior to going to her home, as it was felt that her presentation and mental health had improved. She was usually independently mobile but on 25th and 26th October 2019 she requested a wheelchair and one was brought in from home. She used this to push and walk about the ward. By 31st October 2019 when Sheila Steggles complained of feeling unwell her mobility had declined and she was not coming out of her room. There was no evidence that she was walking then except briefly when seen by a doctor. No specific illness was detected although physical observation and blood tests were done, these were all normal. The same doctor saw her on 1st November 2019 again nothing specific was found. On both occasions Shelia Steggles was examined for a current DVT but no documented formal assessment of her future risk of DVT was made. She had several risk factors, she was over 60, obese and had a past history of DVT. Her reducing mobility was not considered a further risk factor even though it put her into the very high category because it was thought to be due to her mental health and may therefore improve. After the 1st November 2019 the doctor went on leave and left instruction that any further concerns be raised and if needed a doctor would review. Sheila Steggles was not reviewed on 2nd November 2019 and remained on her bed in her room and on 3rd November 2019 another doctor reviewed her, again looking for current DVT but finding none and no consideration was given to her future risk given that her mobility was greatly reduced. On 4th November 2019 a doctor was called for general not specific concerns and he chose not to examine Shelia Steggles since on the notes her presentation had not changed from 3rd November 2019. On the morning of 5th November Sheila Steggles collapsed whilst being moved and suffered a cardiac arrest. Resuscitation was prompt and emergency services attended but she died in the ambulance. An expert opinion concluded that on the balance of probabilities the DVT was not formed before the 2nd November 2019 and that prophylaxis given then would have prevented the DVT and the PE.

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Report details

Reference: 2022-0042
Date of report: 10 February 2022
Coroner: Yvonne Blake
Coroner area: Norfolk

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Apr 2022 (estimated).

Sent to

Hellesdon Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.