Source · Prevention of Future Deaths

Beryl Holland

Ref: 2020-0037 Date: 25 Feb 2020 Coroner: Alison Mutch Area: Greater Manchester South 2 responses identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted a lack of national guidance for managing pressure ulcer risks in Emergency Departments. This can result in inadequate Trust policies, particularly for vulnerable patients experiencing prolonged stays in the ED awaiting ward transfer.

Date 25 Feb 2020

56-day deadline 21 Apr 2020 est. estimated from the report date

Responses identified 2 of 1

Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted a lack of national guidance for managing pressure ulcer risks in Emergency Departments. This can result in inadequate Trust policies, particularly for vulnerable patients experiencing prolonged stays in the ED awaiting ward transfer.

View full coroner's concerns

_ The inquest heard that Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps t0 reduce the risk of pressure ulcers developinglworsening in the Emergency Department: The inquest was told that there is no national guidance relating t0 the management oflreducing the risks of July Beryl pressure ulcers developing in an Emergency Department setting: As a result, Trusts will develop their own policies; which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department:

Responses

2 respondents

National Institute for Health and Care Excellence

Other

Indexed date: 16 Mar 2020 PDF

AI-classified response stance Noted

AI-generated response summary

• NICE stated that its existing guideline (CG179) provides advice on managing and reducing pressure ulcer risks in emergency department settings. • NICE indicated that no further action was required from the organisation in response to the report. • NICE noted it had initiated a multi-year programme, NICE Connect, to review and improve the presentation and accessibility of its guidance.

View full response

Dear Ms Mutch; write in response to your correspondence, dated 25 February 2020, regarding the death of Beryl Holland: was very sorry t0 read of Ms Holland's death We have reflected on the circumstances surrounding Ms Holland's death, &nd the concerns raised in your report, relating (0 guidance on the managing and reducing the risks of pressure ulcers developing in an emergency department setting: The NICE guideline on the prevention and management of pressure sores (CG179) specifically provides advice t0 clinicians regarding patients receiving care in emergency department settings Recommendations 1.1.2 and 1.2.1 contain advice to clinicians on risk assessment for patients receiving care in emergency departments if they have a risk factor; such as: significantly limited mobility (for example, people with a spinal cord injury) significant loss of sensation previous or current pressure ulcer nutritional deficiency the inability to reposition themselves significant cognitive impairment: We therefore consider that NICE has produced relevant guidance and that no further action is required from us at this time in response to your report: We have initiated a multi-year programme of work called NICE Connect to review all elements of the way we produce and present our guidance and advice: The aim of this quality improvement project is to transform the way NICE produces and presents information to users, to ensure it can be found on our website more quickly and easily and is as clear and accessible as possible. We will be working and consulting with stakeholders throughout this long-term project. Further details of this work can be found on our website.

the Department for Health and Social Care

Central Government

Letter dated 28 Apr 2020 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Department for Health and Social Care stated that the National Institute for Health and Care Excellence (NICE) provides a clinical guideline for the prevention and management of pressure sores, which includes recommendations for emergency department settings. • The Department for Health and Social Care noted that NHS trusts are expected to develop local policies based on NICE guidelines, and highlighted the 2017 NHS Improvement emergency department patient safety checklist. • The Department for Health and Social Care indicated that Stockport NHS Foundation Trust has adopted the patient safety checklist and implemented measures such as improved access to dynamic mattresses and patient transfers from trolleys to beds.

View full response

Dear Ms Mutch

Thank you for your letter of 25 February 2020 to Matt Hancock about the death of Beryl Holland. I am replying as Minister with responsibility for patient safety.

Please extend my sincere condolences to Ms Holland’s family and loved ones.

It is important that we look to make improvements where we can to ensure the highest standards of quality and safety in the NHS and I am grateful to you for bringing these matters to my attention.

I am aware that the National Institute for Health and Care Excellence (NICE) has advised you in its response that a clinical guideline is available on the Prevention and Management of Pressure Sores (CG1791) and that this guideline provides specific recommendations to clinicians in relation to patients receiving care in emergency department settings if they have a risk factor. It is the view of NICE that this guideline provides relevant guidance.

NHS trusts are expected to take into account NICE guidelines when developing Trust level policies. Risk assessment and care planning for the prevention of pressure ulcers should be undertaken in all relevant settings within a hospital and it is therefore expected that emergency departments will have local policies in place.

To assist NHS trusts, in 2017, NHS Improvement published an emergency department patient safety checklist2 that can be used to ensure skin assessments, appropriate care plans and follow up care are undertaken and recorded. The checklist is endorsed by NHS England, the Royal College of Emergency Medicine, and the Royal College of Nursing.

1 https://www.nice.org.uk/guidance/cg179

2 https://improvement.nhs.uk/resources/emergency-department-ed-patient-safety-checklist/

I am advised that the Stockport NHS Foundation Trust has adopted the Patient Safety Checklist for use in the emergency department at Stepping Hill Hospital, alongside other actions to improve processes around the identification and management of pressure ulcers. The emergency department works closely with the Tissue Viability Nurse Specialist and working together measures have been developed to improve patient safety and the quality of care. For example, through improved access to dynamic mattresses and the transfer of patients from a trolley to a bed if they are experiencing long waits and are identified to be at risk.

I hope this response is helpful.

NADINE DORRIES

Report sections

Investigation and inquest

On 10h July 2019, | commenced an investigation into the death of Beryl Holland. The investigation concluded on the gth January 2020 and the conclusion was one of Accidental Death: The medical cause of death was 1a) Hospital acquired pneumonia; 1b) Neck of femur fracture; Ic) Fall; Il) Myocardial infarction; type 1 diabetes, pressure ulcers, dementia. CIRCUMSTANCES OF THE DEATH Beryl Holland sustained a fractured neck of femur at the care home where she resided after a fall. She had poor skin integrity and was high risk in relation to pressure ulcers: She was admitted, via the Emergency Department, to Stepping Hill Hospital and operated on. Post operatively she continued to decline. She died at Stepping Hill Hospital on 7th 2019. CQRONER'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_ The inquest heard that Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps t0 reduce the risk of pressure ulcers developinglworsening in the Emergency Department: The inquest was told that there is no national guidance relating t0 the management oflreducing the risks of July Beryl pressure ulcers developing in an Emergency Department setting: As a result, Trusts will develop their own policies; which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power t0 take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 21st April 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely daughter of the deceased; 2) Care Quality Commission, who may find it useful or 0f interest am also under a to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner_ Alison Mutch OBE HM Senior Coroner 25.02.2020 days duty

Circumstances of the death

Beryl Holland sustained a fractured neck of femur at the care home where she resided after a fall. She had poor skin integrity and was high risk in relation to pressure ulcers: She was admitted, via the Emergency Department, to Stepping Hill Hospital and operated on. Post operatively she continued to decline. She died at Stepping Hill Hospital on 7th

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power t0 take such action.

Similar PFD reports

Shared signals

Report details

Reference: 2020-0037
Date of report: 25 February 2020
Coroner: Alison Mutch
Coroner area: Greater Manchester South

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Apr 2020 (estimated from the report date).

Sent to

National Institute for Health and Care Excellence

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.