Source · Prevention of Future Deaths

James Francis

Ref: 2019-0202 Date: 19 Jun 2019 Coroner: Penelope Schofield Area: West Sussex 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryIneffective shift handovers meant staff were unaware of a patient's recent fall and the need for increased observations, a gap compounded by insufficient management checks. There were significant delays in seeking medical advice for a deteriorating patient, and vital information was not adequately provided to the GP or paramedics.

Date 19 Jun 2019

56-day deadline 18 Oct 2019 est. estimated from the Judiciary.uk publication date

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Ineffective shift handovers meant staff were unaware of a patient's recent fall and the need for increased observations, a gap compounded by insufficient management checks. There were significant delays in seeking medical advice for a deteriorating patient, and vital information was not adequately provided to the GP or paramedics.

View full coroner's concerns

1) Effectiveness of shift handover meetings heard evidence from several staff members at different grades Including two support workers responsible for Mr Francis's daily care_ a senior support worker and team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out In particular; both support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities It was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that However, It certainly seems that both support workers observed Mr Francis on a regular basis throughout the and took appropriate action to report his condition and any change to senior staff In another patient; this lack of handing on of vital information to members of staff could be crucial was shown a shift handover form but this IS basic and contains no additional guidance or method to highlight particular concerns or need for Increased observations
2) Monitoring & management checks Related to Item above, Is the fact there seem to be a fallure of appropriate management records and checks to ensure that If 30 minute observations were The key day day key required that these were undertaken at regular intervals
3) in calling a GP or making a 111 call for advice & information given to GP when requesting Home visit heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the of his fall, no action was taken to seek out of hours medical advice In addition, despite a significant deterioration in Mr Francis condition later In the of his fall and more significantly the following morning and after five separate referrals by the support worker to the team leader; there was a five hour making a simple telephone call to request a GP visit Further; there does not appear to have been any thought given to making a call to NHS 111 for advice was also unclear exactly what information was given to the GP surgery to stress the history deterioration in Mr Francis condition
4) Sufficiency of information given to paramedics & position of patient on the floor heard evidence that the Ambulance crew received the call to attend Deerswood at 15 22 and arrived at 15 25 reported that found Mr Francis on the floor leaning up against the room chair and over to his right side accepted that they were assertive but felt this was born from a frustration to find a time critical patient In such a position and staff were unable to answer basic questions about past medical history, allergies, mobility, communications for current medication appeared to the crew that Mr Francis may have slipped out of the chair and his position may have compromised his breathing knew the dispatch occurred at 15 15 and arrived 15 27 so 12 minutes was available to the care home staff to prepare for their arrival and gather together all the required Information Their joint recollection was that found some paperwork Including details of other residents and amongst those papers they found some details of Mr Francis medical history and current medication including balance issues previous brain tumour In 2010 and that he was prescribed Riveraxaban plus there was a history of falls The crew were not concerned that Mr Francis was on the floor and felt that the recovery position would have been far better than the slumped position they found him In Nevertheless, they accepted that Mr Francis breathing was fine Again It took some time to obtain all the detalls of the fall and sickness detalls Finally, when leaving the building to the stretcher trolley one of the paramedic crew heard care home staff arguing about the sickness detalls that had not been documented This evidence raises considerable concern regarding the adequacy of documenting events In a patient's care such as a fall even If the patient indicates there was no acute trauma particularly when the patient IS elderly and has complicated past medical history In addition, the paramedic suggested that other care homes have a document that can be Instantly handed over to them to speed up the handover procedure and ensure that clinical staff have a full Information This IS often called a Hospital Passport and uses simple traffic light alerts to highlight information There was no evidence of this kind of simple document in this case
5) Staff training heard evidence from a number of staff members that they had received no training at all or It was some time (up to 3 years) since they had had any basic first ald training In addition, the paramedics indicated that when the care home staff were asked what their protocol and understanding was of a head injury With someone who was prescribed anticoagulant_ It seemed the staff could not answer Nor could Delay day day day delay and They they dining They They they they get key key history key key they spot the signs and symptoms of head Injury even though this IS basic first-aid It would seem the care home staff had not considered placing Mr Francis on the floor Into the recovery position until requested to do so by the 999 operator From reading the transcript it suggests that when the operator asked the staff to do this, efforts were made to comply and then ensure Mr Francis head was tilted to keep the airway clear and his breathing became a little less shallow Conversely, the ambulance crew were both very clear that their Immediate concern on entering the room was the poor position of Jim In a seatedlslumped position that may have compromised his airway In addition one of the team leaders confirmed that she knew Mr Francis had a VP shunt In place but she was not aware of his past medical history or indeed what shunt did. This raises concerns about basic aspects of patient care and the adequacy of staff training
6) Adequacy of NICE guidelines heard expert evidence from Prof Mark Wilson, consultant neurosurgeon and prehospital care specialist at Imperial College NHS Trust He confirmed that what was more lkely to have happened was that very minor trauma triggered the formation of the subdural haematoma His view was that the shearing force of landing on his bottom and missing the bed or wheelchair cause stretching and rupture of one of the cortical veins leading to the bleed In other words there was no direct head injury but Instead there was movement of the brain within the cranium When considering the care and treatment of Mr Francis at Deerswood Lodge from the time of the fall to the admission to hospital and whether the In seeking medical advice and attention caused or contributed to death; there was a discussion about relevant NICE guidelines concerning head injuries and falls The suggestion was that the existing guidelines may not sufficiently address the fact that type of fall In the elderly also needs to be considered non-traumatic head injury leading to a shearing effect on the brain The suggestion was that this type of slow bleed may take significantly longer to manifest In terms of observable symptoms such as a change In alertness or persistent vomiting It certainly seems that the care home staff did not make the connection As a result; this raises concerns as to whether this type of Incident which must be frequent in the elderly Is adequately taken Into account in relevant NICE guidelines

Responses

2 respondents

National Institute for Health and Care Excellence

Other

Indexed date: 19 Jun 2019 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The National Institute for Health and Care Excellence stated that its guideline on head injury (CG176) is undergoing a surveillance review. • The review is likely to conclude that an update is required to clarify the guideline's applicability to indirect head injury. • A final decision on the surveillance review is due to be published in September 2019.

View full response

Dear Ms Harold, Thank you for your letter, dated 19 June 2019, regarding the tragic death of James Willam Francis We have considered the circumstances surrounding Mr Francis' death and the concerns raised in your report and in particular the concerns that existing NICE guidance on head injury may not be appropriate for Instances where a person experiences non-direct head trauma We consider that the NICE guideline on the assessment and early management of head injury (CG176) Is relevant to the circumstances described, since It covers the assessment and early management of head injuries caused by both direct and indirect traumas This includes all patients who presented with a suspect or confirmed traumatic head injury WIth or without other major trauma The guideline defines head injury 'as any trauma to the head other than superficial injuries to the face In addition, the guideline specifically defines a 'closed head injury' as a blow to the head or a severe shaking causing tearing, shearing or stretching of the nerves at the base of the brain, blood clots In or around the brain or oedema (swelling) of the brain. There IS no penetration of the skull or brain tissue by an object; the skull may be fractured but this does not result In a direct connection between the brain and the outside (see Penetrating Brain Injury)' This definition can be found In the glossary within the full guideline document for CG176 The guideline IS currently undergoing a surveillance review exercise to determine whether It should be updated As a result of your report; the review IS likely to conclude that an update IS required so that It IS clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users) A final survelllance review decision IS due to be published in September 2019

Shaw Healthcare

Indexed date: 14 Aug 2019 PDF

AI-classified response stance Action Taken

AI-generated response summary

• Shaw Healthcare implemented a 'Shift Handover Form' and a detailed handover process to improve communication of critical patient information. • A revised 'Prevention and Management of Falls Policy' was put in place, alongside training for staff on 'Recognising a Deteriorating Service User' and first aid. • The organisation recruited Quality Improvement Managers and adapted a Hospital Passport Transport Traffic Light System to enhance information sharing with paramedics.

View full response

Dear Madam Prevention of Future_Death Report_ Your Ref: 01109-2019 Deerswood Lodge,West Sussex We are responding in receipt of your Regulation 28 Report to Future Deaths Report and covering letters addressed to Shaw healthcare Ltd namely Jeremy Nixey (Chief Executive) and (Director of Nursing and Health and Safety) of 20th June 2019. am writing to you on behalf of Shaw healthcare: Firstly would like to record again our condolences and on-going thoughts to the later Mr Francis'$ family and to confirm that both locally at Deerswood Lodge residential care home and within the Shaw healthcare Group we have learned significantly, completed a number of revisions and actions both locally and nationally which within this letter will clarify details on actions we have taken and salient timescales. Within your report you raised six specific matters of concern where actions were required_
1) Effectiveness of shift handover meetings
2) Monitoring & management checks
3) Delay in calling a GP or making a 111 call for advice & information given to GP when requesting Home visit
4) Sufficiency of information given to paramedics & position of patient on the floor
5) Staff training Adequacy of NICE guidelines which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revised set of NICE guidelines_ Registered Ollice Shaw healthcare (Group) Limited Links Court Links Business Park St. Mellons Cardiff | CF} OLT EAC Housing @shawhealthcare UK Over 50"$ Housing Awards (029) 2036 4411 (029) 2036 4322 info@shaw co.uk WWWV.shaw co.uk shawhealthcare National Caring Times Care Awards Registered under (he Companes
985. Rpgistration `o 5J91089 Reri ed England Males

Shaw healthcare Our responses and actions to areas 1 to 5) are as follows: Effectiveness of shift handover meetings Prior to your inquest we had already recognised a need to improve our handover arrangements at Deerswood and in March 2018 we had set up the attached "Shift Handover Form In addition we expect the following process to be completed at every handover at every service: - a) Identify the personnel who need to attend the handover, ensuring cover is available. b) Person in Charge on outgoing shift must handover to Person in Charge on incoming shift c) Conduct handover in a detailed concise manner using the corporate Handover Form: d) Record start time and end time of handover. e) Provide verbal and written information regarding: All Service Users (Names)
b. A brief summary against Service User' $ names Complete the tick boxes where relevant f) All written and verbal communication to maintain Service User confidentiality and comply with good practice and data protection legislation and guidance_ g) Confirm those who are receiving the handover have understood the information provided and clarify any resulting queries or concerns: h) The Handover form must be signed by the Person in Charge on the out going shift and the Person in Charge on the incoming shift. i) Incoming Person in Charge must allocate staff to locations, Service User, worker groups: j) Incoming Person in Charge to allocate keys, pagers, DECT phones etc where appropriate_ k) Within 30 minutes of taking handover the incoming Person in Charge must check all service users in the building i.e. walkabout and headcount and must undertake a visual check on those identified as deteriorating or poorly: The incoming Person in Charge must sign the Handover Sheet to confirm. To include a security check of the building: The completed handover sheets are to be filed in the designated folder in the Unit Office and remain accessible for future reference_ This action has been completed and will be reviewed on an on-going basis.
2. Monitoring & management checks In November 2017 we had implemented a completely revised "Prevention and Management of Falls Policy which have also attached for verification_ The objectives of this policy are to ensure Service Users who are at risk of falls are identified on admission to the service; Multi-factorial falls risk assessments identifies person centred risk factors for falls; Effective management, treatment and safe care of the Service User is delivered immediately after a fall; the risks of further falls is minimised through the implementation of effective, person centred interventions_ And we seek that all staff should read the policy in conjunction with the Head Injuries policy and the Bed Rails Policy. 2/4 key-

Shaw healthcare Each Service User has a Falls Risk Assessment (and also attached) which we require the newly admitted person to be assessed and completed within 4 hours of their admission to any Shaw care home_ Re-assessments should be completed following any fall and/or as appropriate Each service has an IPRO Falls Risk Tracker in place where the home manager will be completing on-going assessments, analysis and review within their service. This action has been completed and will be reviewed on an on-going basis
3.0 Delay in calling a GP or making a 111 call for advice & information given to GP when requesting Home visit We have all learned from the regrettable circumstances surrounding the deterioration in Mr Francis's condition during the latter part of the of his fall. All care staff now receive training on "Recognising a Deteriorating Service User and in addition also all receive first aid training also refer to the attached "Request for attendance of GP" policy which states that if a Service User develops a health problem or if the Service User requests to see their GP, the senior person on duty will assess the situation and contact the surgery, before the medication round commences. In assessing the urgency of the situation, the GP Surgery can be approached for advice or otherwise to liaise with the District Nursing service as appropriate it goes on to set very clear expectations in referring to the NHS 111 service also and the importance of clear communications. We expect every service manager to monitor this within their service and our auditing systems at local level check the application of this. This action has been completed and will be reviewed on an on-going basis.
4.0 Sufficiency of information given to paramedics & position of patient on the floor Care planning, daily records from assessments and evaluations continue to be improved at Deerswood _ For our 12 care homes in West Sussex we have recruited two Quality Improvement Managers where their primary function is to ensure improvements in service provision including the completion of care records with mentoring, supervising and role-modelling to care and nursing staff_ also note that paramedic referred to the Hospital Passport. We have adapted the Hospital Passport Transport Traffic Light System within all our West Sussex care homes initially and through the wider company_ This is to provide the paramedic and hospital staff the most helpful information that isn't only about illness and health: This accompanies the Service User to inform and support. It is implemented within our Care Plan systems. In addition the increase in training including the "Recognising a Deteriorating Service User" and first aid training reported in 3 above and in our response to area 5 covers the necessary need to improve communication not just to GPs and paramedics but to all relevant professionals. This action has been completed and will be reviewed on an on-going basis. 3/4 day they along

Shaw healthcare
5. Staff training We have covered the very necessary responses required by you throughout this report: We have significantly increased training and awareness, service has a completed Training Metrics where we expect 90% of all staff at any one time to have completed all mandatory training: All Shaw healthcare employees caring/working with any Service Users who is at risk of falling will be Up to date in their Manual Handling training and their competency assessed by a senior staff member who has been accredited by the Company. They must attend a first aid training course and ensure that this certification remains current throughout their employment: And we require all First Aiders to respond to any first aid situations by following the correct first aid procedure: There is at least one First Aider on duty at every shift: This action has been completed and will be reviewed on an on-going basis. In conclusion, we respectfully regret the events surrounding Mr Francis'$ fall at Deerswood, we all that is the management and staff at Deerswood Lodge, the wider regional management and nationally of Shaw healthcare have learned from this incident: We have taken some tough and necessary actions and we have changed our practice, training and policies. If you require any further information or detailing please do not hesitate to contact me.

Report sections

Investigation and inquest

On 25 April 2017, the Senior Coroner, Penelope Schofield, commenced an investigation Into the death of James Willam Francis aged 79 years old The Investigation concluded at the end of the Inquest on 6 July 2018 recorded a narrative conclusion as follows James William Francis had a history of falls and balance Issues arising from previous brain surgery and the insertion of a VP shunt unwitnessed fall in his room on 9 April 2017 caused him to slp onto the floor either from his bed or a wheelchalr This minor trauma was Iikely to have caused a shearing effect from movement of his brain within the cranium and led to stretching then rupture of one or more of the cortical veins He was sick three times some 10 hours later and again overnight Medical assistance was not sought His condition deteriorated the following morning and a call to a GP surgery was delayed by 4 hours Further sickness and other symptoms were not recognised until unconsciousness occurred and this led to an ambulance being called and admission to hospital where a CT scan confirmed a life threatening clot compressing the brain Surgery was not advised and despite attempts to reverse anticoagulation medication Mr Francis died on 11th April 201 after palliative care Expert medical evidence confirms that earlier admission to hospital would not have altered the final outcome The medical cause of death was recorded as 1a) Subdural Haematoma 1b)Brain Injury Nixey, The

1c) Fall

Circumstances of the death

Mr Francis was a 79 year old gentleman (DOB 8 July 1937) who lived at the Deerswood Lodge Care Home (the Home) In Crawley, West Sussex He was admitted to Deerswood Lodge from daughter's home on January 2016 His past medical history Included a left occipital craniotomy and insertion of a VP shunt in 2001 following hydrocephalus, acoustic neuroma In 2005,and reported TIA in 2013 As a result; the Home noted he had periods of unsteadiness and balance difficulties resulting In a history of falls and he was prone to urine infections He was able to walk short distances with the assistance of a frame although he required a wheelchair for longer distances He was on anti-coagulation medication (Rivaroxaban) Mr Francis had a previous fall at the Home on March 2017 when he fell from bed and bumped his head on the floor resulting In a slight bump and graze on the left side of his head An ambulance was called and he was taken to hospital but returned to the Home later the same He had another unwitnessed fall on Sunday 9 April 2017 heard evidence from Jim's wife when she visited the home at noon was In the garden In the shade having a cup of tea He told her that he had slipped off the bed and landed on his bottom After discussion with the family during the Inquest;, It was suggested that because Jim's legs were weak he may very well have tried to lever himself up off the bed and his feet slipped under causing him to land on the floor on his bottom told that he had hit his head and had told the staff By contrast; the night support worker confirmed in her statement that the sensor was activated In Jim's room at around 07 30 hours She found Jim on the floor and pressed the emergency button Jim did not wait for help and levered himself back onto the bed He was asked f he had hit his head and sald no When asked how he had fallen to the floor; told Ithat he was trying to sit on his wheelchalr and the wheelchair ran out behind He was checked by a Team Leader for injuries but no bruises were noted and he indicated that he had not struck hIs head He remained responsive but was placed on 30 minute observations In with standard practice In the Home During the Mr Francis spent time In the garden and was visIted by his family By 17 30 _ 18 00 Mr Francis told a support worker that he had been sick In the bathroom By 19 00 19 30 he told the same care worker that he had been sick In bed and this happened again between 20 30 21 00 requiring a change of bedsheets He was therefore sick three times between 17 30 and 21 00 This was reported to more senior experienced staff but no telephone advice was obtained Night shift staff started around 22 00 and sometime after 22 00 a support worker heard Mr Francis vomiting so With the Team Leader they got Mr Francis out of bed moved him Into the lounge to prevent choking A few hours later there was a second episode of vomiting and some water was noted He was monitored until morning but he stayed upright in a chair In the lounge No call was made to a doctor or telephone advice obtained By Monday morning Mr Francis condition was deteriorating his day care worker could see Jim was uncomfortable and trying to be sick He went straightaway to Inform the senior nurse at about 08 40 to 08 45 She said to observed Jim until she could ring for a GP to attend This call was not made until four hours later at 11 40 after five separate reports from support staff including the fact Jim was slurring his speech Indeed, the care worker discussed the need for a doctor to attend with Jim's wife at 11 00 such was the level of his concern The Team Leader says the call was at 10 40 but the manager reports the call was made at 11 41 Standard practice was for GP visits normally to occur In the afternoon By 11 40 a support worker reported that Mr Francis was sick again and that this time It his his day Jim from him Jim Jim from him line day, and and and very day was black but he wasn't sure If blood was present Other members of staff heard Mr Francis being sick and this was reported to the Team leader plus It was reported that he was burning up By 15 20 the shift handover notes recorded that Mr Francis had become unresponsive so a 999 call was made The ambulance arrived at 15 26 and left with Mr Francis at 15 49 arriving at the East Surrey hospital at 16 05 A CT scan revealed a large right holohemispheric sub dural haematoma extending into the falx cerebri and tentorium cerebelli causing 1 6cm midline shift and there was evidence of uncal herniation on the right side Advice was taken from St George's Neurosurgical team and a registrar advised by telephone at 16 59 as follows Not an appropriate candidate for acute neurosurgical intervention Best supportive medical management Liaise with haematology reverse rivaroxaban/ any coagulopathy (aiming INR<1 2, platelets >100), hold any blood thinning medications; ensure electrolytes are kept within normal range Neuro obs If survives acute presentation; repeat CT head In 2 weeks and rediscuss With US at point Mr Francis was treated In accordance with this advice but he sadly died on the 11 April 2017 Following his death no Post Mortem examination was carried out In light of the radiology report and doctor's referral of a death to the Coroner by from East Surrey Hospital giving cause of death as 1a) Subdural haematoma_ 1b) Head Injury

Action should be taken

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

Similar PFD reports

Shared signals

Report details

Reference: 2019-0202
Date of report: 19 June 2019
Coroner: Penelope Schofield
Coroner area: West Sussex

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Oct 2019 (estimated from the Judiciary.uk publication date).

Sent to

National Institute for Health and Care Excellence

Shaw Healthcare

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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