Source · Prevention of Future Deaths

Valmai West

Ref: 2021-0239 Date: 13 Jul 2021 Coroner: Caroline Saunders Area: Gwent Responses identified: 1 / 1 View PDF

Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.

Date 13 Jul 2021
56-day deadline 7 Sep 2021 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
View full coroner's concerns
1. Staffing Levels in the Emergency Department of Royal Gwent Hospital During the course of the inquest, consideration was given to the the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr , Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ' assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk.

Responses

1 respondent
Aneurin Bevan University Health Board NHS / Health Body
3 Sep 2021 PDF
Noted

The Health Board reviewed nurse staffing levels which they state were adequate at the time of the incident. They have also commissioned an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital, and a similar review of medical staffing is also being undertaken. (AI summary)

View full response
Dear Ms Saunders Re: Aneurin Bevan University (Health Board response to Regulation 28 Report received following the inquest touching upon the death of Mrs Valmai Ann West, DOB 05/10/1939 Thank you for your report dated 13th July 2021, which was received by the Health Board on the 14th July 2021. The information within the response letter has been compiled by , Executive Director of Nursing. In response to your report, the information provided is intended to address the concerns raised by Dr s during the course of the inquest. It was acknowledged that staff had not followed hospital protocol or NICE guidelines in relation to the frequency of which observations should be performed. Dr assessment of the situation was this was probably due to inadequate nurse staffing levels within the Emergency Department. Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations. I thought it would be helpful to share that an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital was commissioned as a result of the early opening of the hospital and in light of increased patient demand. This has been undertaken by the Bwrdd lechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board Pencadlys, Headquarters Ysbyty Sant Cadog St Cadoc's Hospital Ffordd Y Lodj Lodge Road Caerilion Caerleon Casnewydd Newport De Cymru NP15 3XQ South Wales NP18 3XQ Ff6n: 01633 436700 Tel No: 01633 436700 E-best: abhb.enquiries@wales.nhs.uk Email: abhb.enquiries@wales.nhs.uk Bwrdd Iechyd Prifysgol Aneurin Bevan yw envy gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board

-2- Senior Nurse Manager for ED and the Assistant Head of Nursing, supported by the Deputy Director of Nursing. The assessment is based on RCN Guidance, RCEM Guidance, Nurse Staffing Levels (Wales) Act 2016 and, importantly, professional judgement. A similar review of medical staffing is also being undertaken. I hope this additional information in relation to the matters raised is helpful in terms of clarification but also as an update on progress and assurance in relation to nurse staffing levels within the Emergency Department at the Grange University Hospital and those raised in regards nurse staffing levels at the time of the incident. Do not hesitate to contact me should you require any further information.

Report sections

Investigation and inquest
On 28/1/2020 an investigation was opened into the death of Valmai Ann WEST The investigation concluded at the end of the inquest on: 1/7/2021 The conclusion of the inquest was recorded as: Death By Accident The medical cause of death was: 1a) Intracranial Haemorrhage 1b) Fall
Circumstances of the death
Valmai West suffered 2 falls in the community on 111h and 16th January 2020 respectively and attended the Emergency Department of the Royal Gwent Hospital. On neither occasion did she present with any signs of intracranial haemorrhage or cerebral irritation. Mrs West had also suffered a fracture of her pubic ramus on 16th January and was admitted to hospital for management of the fracture and rehabilitation. On 20th January Mrs West was found to be unresponsive and a CT scan demonstrated an extensive subdural haemorrhage. The effect of this bleed was devastating and Mrs West died on 22nd January 2020 at the Royal Gwent Hospital.
Action should be taken
I should be grateful if the following information be provided to me:
1. Confirm whether any steps have or will be taken to address the staffing levels within the Emergency Department or other steps to ensure that there is sufficient capacity to undertake essential duties such as neurological observations.

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Report details

Reference
2021-0239
Date of report
13 July 2021
Coroner
Caroline Saunders
Coroner area
Gwent

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 Sep 2021 (estimated).

Sent to

Aneurin Bevan University Health Board

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