John Preece

Coroner's concerns

AI summary

Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.

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; (1) There was a clear lack of understanding and basic knowledge of falls management by both trained nurses and support workers in circumstances in which it should have been obvious that Mr Preece sustained a head injury: The evidence clearly revealed that there was knowledge of a head injury following his seizure and fall. Even if that were not the case a head injury should have been suspected (2} There was & clear lack of knowledge amongst all staff, both registered nurses and support workers as to how to conduct neuro observations despite the evidence showing that guidance in the form of health board policy and also a "wall chart" was available to be consulted (3) There was no forward planning for the continued observations of Mr Preece throughout the on gih September 2015 and as a result he was simply put to bed and not closely monitored as the circumstances required (4) The evidence revealed that none of the registered nursing staff were trained either during their basic nurse training or subsequently upon employment within the health board, on how to conduct neuro observations and that together with a failure to appreciate an obvious head injury meant that not only observations conducted but that no medical assistance was sought for at least ten hours: (5) Evidence given at the inquest showed that the health board had considered the introduction of the NEWS scoring system (National Early Warning System) for the Mental Health Directorate but felt unable t0 introduce it as the mental health unit did not sit withinlalongside a district general hospital The obvious concern being that against a background of poor training and poor management medically unwell mental health patients are at risk

Responses

2 respondents

University Health Board

11 Mar 2019 PDF

Action Taken

The Health Board has implemented a falls training program developed by Practice Nurse Educators, introduced an escalation policy specifically for St Barruc ward, and uses NEWS across MHSOP wards in University Hospital Llandough with clear escalation policies. (AI summary)

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Dear Mr Barkley Touching upon the death of the late Mr John Preece Thank you for your letter which we received on 16 January 2019. The University Health Board (UHB) has reviewed the points ralsed within the Regulation 28 report with relates to the very sad death of Mr Preece. Our response has been Informed by key clinical staff within Mental Health Clinical Board, We recognise that this will have been a very difflcult time for Mr Preece'8 family and would like to offer out most sincere condolences: The matter has been fully investigated and there Is a comprehensive improvement plan in place which is being monitored by the Clinical Board_ For ease of reference, will respond to each of matters of concer you raised in tum: 1 There was clear Iack of understanding and basic knowledge of falls management in both tralned and support workers In circumstances In which it should been obvlous that Mr Preece sustained a head injury: The evldence clearly revealed that there was knowledge of a head Injury following his seizure and fall: Even if that were not the case a head injury should have been suspected: Mental Health Clinical Board run a bespoke falls training programme which has boen developed by the Practice Nurse Educators within the Mental Health Services for Older People (MHSOP) Directorate_ The sessions specifically include training on falls risk management (to identify measures to reduce the risk Of a patient falling} post falls management; responding to an unwitnessed Or witnessed fall and performing neuro observations. This training is dellvered on & programme and so far, approximately 75% of nurses (both qualified and unqualified) within MHSOR Brred Artyto Caarhrdd !r Fro yh em Dwechredol Bwrtud ledtyd Uccl Frthyeool Ctrdydd !r Fro Cardin and Vik Untenhy Haam Daxrd the pocredonal mn 01 Cardin and Vaka Unlvmty Lcy Hukth Doand Fro the have have rolling Laro

and Adult Mental Health have attended this training: 37 out of 42 nurses working on St Barrac's ward have completed this training and arrangements are in place for the outstanding 5 nurses to attend tralning soon. The UHB has recently opened a falls simulation training suite In the University Hospital of Wales (UHW) ad there are plans for a further suite to be sited in University Hospital Llandough All qualified and support staff are encouraged to attend simulation workshops on falls prevention management and post fall care: The tralning covers the management of an unwitnessed fall including how to respond to a head injury: One of the Nurse Advisors for Standards and Professional Practice is currently working week with nursing staff In MHSOP reviewing patients who have been assessed to be at high risk of falling: The purpose of this work is to try and identify other preventative measures to further reduce the risk of falling: 2 There was a clear lack of knowledge amongst all staff, both registered nurses and support workers as to how to conduct neuro observations despite the evidence showing that guldance in the form of health board pollcy and also a "wall chart" was available to be consulted: Training on neuro observations Is included in the bespoke Mental Health tralning programme and also in the UHB wide falls simulation training: new neuro observation chart was introduced in August 2018 and it is now UHB policy that only registered nurses perform this task:
3. There was no forward planning for the continued observations of Mr Preece throughout the day on gt September 2015 and a8 a result he was simply put to bed and not closely monitored as the circumstances required There are clear escalation processes in place and our Interal investigation identified that 2 nurses did not follow this process. They were managed by UHB disciplinary procedures and have now been referred to the Nursing and Midwifery Council for further investigation:
4. The evidence revealed that none of the reglstered nursing staff were trained elther during their baslc nurse tralning or subsequently upon employment wlthln the health board; on how to conduct neuro observations and that together with a fallure to appreclate an obvious head Injury meant that not only observations conducted but that no medical asslstance was sought for at least 10 hours: In 2015 undergraduate nurse training did not cover how to perform neuro observations but this task now been added t0 the curriculum and as mentioned above, training on how to perform neuro observations is now included in falls training within the UHB: Brndd lachrd Prltysnol Cerdrdd Ar Fmo ye e Detlthnedol Brynd Ieod Lkdl Prilytgel Cuntydd !r Fro Onm tnd Vlk Unterttty Hutnn Bon tha optrtbne| nime & Ordin und Vele Unlenty Lal Huth Brd day_ has

5. Evidence given at the inquest showed that the health board had considered the Introduction of the NEWS scoring system (Natlonal Early Warning System) for the Mental Health Directorate but felt unable to introduce it as the mental health unit did not slt withinlalongside a dlstrict general hospltal. The obvious concern being that against a background of poor training and poor management medically unwell mental health patients are at risk; St Bamuc ward is part of Barry Hospital which is not attached to one of the UHB's main hospital sites. Barry Hospital is a community hospital with in-patient wards and other community out-patient services: MHSOP Directorate are not able to guarantee the level of medical cover at Bamy Hospital (there is no 24 hour medical cover) hence it has not been possible for the NEWS monitoring system to be implemented there in the same way as it has been implemented in the district general hospitals where medical staff are available on-site at all times: MHSOP have therefore introduced an escalation policy specifically for St Barruc ward covering in and out of hours This policy gives nursing staff guidance on who to contact for medical advice and who to escalate any concems to. NEWS is used across MHSOP wards based in University Hospital Llandough to assist nurses and medical staff in determining degree of illness of a patient and again there are clear escalatlon policies in place, if nurses identify a patient whose NEWS score Is deteriorating or if they have general concems. hope that the inforation set out in this letter provides you with the assurance that the Health Board has fully considered the issues raised as a consequence of the inquest Into Mr Preece's death, and has taken appropriate action in response.

NMC Regulator / Inspectorate

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Noted

The NMC outlines its regulatory role in setting and maintaining standards for registered nurses and refers to new standards and assurance processes to ensure nurses entering the register are properly trained. They will pursue any regulatory concerns which it is appropriate for them to take, through their fitness to practise procedures. (AI summary)

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Dear Sir RE: The Late John Preece Regulation 28 Prevention of Future Deaths Report am writing to respond to your report to Prevent Future Deaths made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and to explain the action we've taken or propose to take in relation to the issues you've raised. Firstly, would like to offer my sincere condolences to Mr Preece's family, and to assure you and them that we take the concerns you have raised seriously: To help you understand the actions we have taken t0 address your concerns in this case, it may be helpful if first explain our regulatory role in setting and maintaining standards for registered nurses: Our statutory functions and objectives We are a statutory body created by the Health Act 1999 and governed by a number of pieces of secondary legislation. Our functions are set out in Article 3(2) of the Nursing and Midwifery Order 2001 ("the Order): The principal functions of the Council shall be t0 establish from time to time standards of education, training and conduct and performance for nurses, midwives and nursing associates and t0 ensure the maintenance of those standards; Our approach to regulation is necessarily circumscribed by our legislation. It also reflects what the Professional Standards Authority ("PSA") has described as "right touch regulation" . 23 Portland Place; London W1B 1PZ T 020 7637 7181 wwwnmcorguk We are the professional regulatory body for nurses and midwives in the UK. Our role is to protect patients ad the public through efficient ad effective regulation;

Aegistered charity in England and Wales (1091434)- in Scotland I(5c038362} RECERE very and

Our Education and Training Standards In order to begin their professional life as a registered nurse, each nurse must obtain qualification' which has been approved by us as demonstrating that the nurse has met our standards of proficiency for nurses ('proficiency standards') . Our proficiency standards are the standards we consider necessary for safe and effectivve practice as a nurse at the of entry to our nursing register: We also set standards for providers of nursing programmes ('education standards') , which are the standards of education and training we consider are needed to achieve our proficiency standards. We ensure, through our statutory quality assurance processes, that we only approve education institutions and nursing programmes which meet our standards In 2016 we identified education for nurses and midwives as a key priority, and embarked on programme of change designed to ensure that our standards remained contemporary and fit for purpose to protect the public. Between June and September 2017 we conducted a full public consultation on our proposed new standards, during which we heard from over 2000 individuals and many organisations. Our new standards were approved by our Council in March 2018, and since 29 January 2019 it has necessary for all education providers to seek approval against these new standards if they wish to continue offering approved nursing programmes: Links to our new nursing proficiency standards and our new education standards may be found here: https IIwWW nmc org uklstandards Nurses joining our register Reading our new proficiency standards, you will see that are clearly designed to ensure that all nurses applying to join our register are able to provide holistic, people- centred care in a context of continual change including challenging environments, different models of care delivery, shifting demographics and evolving technologies. specify the knowledge, skills and attributes that all nurses, whatever their area of specialism, must demonstrate when caring for people of all ages and backgrounds, are designed to ensure that are able to care for people with complex mental, physical, cognitive and behavioural care needs in a variety of care settings. In particular; you will see that the proficiency standards state that at the point of registration, registered nurses must be able to safely demonstrate that they can use evidence-based approaches to take histories, observe, recognise and assess people of all ages, and use evidence-based best practice approaches to undertake, respond to and interpret neurological observations and assessments, and identify and respond to signs of deterioration?. The law on Mutual Recognition of Professional Qualifications applies to nurses applying to join our register from the EU. See in particular our Proficiency Standards: Platform 3 "Assessing needs and planning care' and Platform 6 "Improving safety and quality of care'

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Professional standards for registered nurses Once nurses are registered, are required to uphold throughout their careers the professional standards contained within 'the Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates' (NMC 2018) https IlWWnmc org uklstandardslcode: The Code contains (amongst others) requirements that nurses maintain the knowledge and skills need for safe and effective practice, complete the necessary training to carry out a new role, and raise concerns immediately if are asked to practise beyond their role, experience and training: In order to maintain their registration, every nurse must 'revalidate' their registration every three years to ensure that practise safely and effectively and their skills up to date: The revalidation process requires them to demonstrate that they have practised for at least 450 hours, obtained at least 35 hours of CPD, reflected on their practice, including their adherence to the Code, and obtained five pieces of practice related feedback: Our Fitness to Practise process and our Employer Link Service In appropriate circumstances, we enforce the standards set out in the Code through our fitness to practise proceedings. Depending on the seriousness of the case, our fitness to practise (FtP) proceedings can result in us providing advice or warning; accepting undertakings, imposing a caution or a conditions of practice order or suspending or removing a nurse from our register: We also expect employers to recruit and train their nursing staff appropriately and to support their staff in upholding the standards in the Code, and we reinforce this through regular meetings between members of our Employer Link Service and employers across the UK Where an issue comes to our attention relating to the provision of safe nursing care, we may advise employers to take appropriate action, or if appropriate, take action ourselves. Where the issue falls outside our remit (for example because it relates to systemic problem) we refer the issue to the appropriate regulatory body: Specific action we are taking in this case You have asked us to provide details of action we have taken or propose to take in relation to the concerns you have raised. With regard to your concern that the nurses in question may not have been trained in some basic areas during their nursing training; we are not in a position to confirm the specific details of any particular individual's original nursing training: However, hope that have reassured you that we are doing everything we can through our new standards and assurance processes to ensure that nurses entering our register and maintaining their registered practice are properly trained in managing falls and conducting observations, no matter what their area of specialism, the age or background of the person are caring for; or the context in which are providing care

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Also, for data protection reasons, we are unable to comment publicly on whether we are taking any regulatory action in relation to the fitness to practise of any of the nurses involved However; can confirm that we are aware of their identities, and that we will pursue any regulatory concerns which it is appropriate for us to take, through our fitness to practise procedures. Outcomes of our fitness to practise proceedings are published on our website, and any restrictions we impose on any nurses' fitness to practise are reflected on our public register: We note that you have also written to the Cardiff and Vale University Health Board: will no doubt explain in their response the relevant training, if any, which nurses in this unit had received, and any relevant steps they are taking to learn from this tragic incident: can confirm that we will be drawing the concerns you have raised to the attention of the Healthcare Inspectorate Wales, so that aware of the issues (if are not already) and can take any appropriate action. hope that this letter reassures you that we are doing everything we can to address the concerns you've raised, within the scope of our statutory remit: If you have any further questions concerning this case or the action we have taken, please do not hesitate to in touch_

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Investigation and inquest

On the 17th September 2015 commenced an investigation into the death of John Preece aged 62. The investigation concluded that the end of the inquest, sitting with a jury on the 13uh December 2018_ The conclusion of the inquest was that of a narrative conclusion, namely 'Mr Preece died of a subdural Haemorrhage as @ result of a traumatic brain injury following a fall"_ The in hearing the inquest was in the main due to a criminal prosecution before the crown court

Circumstances of the death

These were recorded as The deceased John Preece suffered with early onset dementia which was diagnosed in 2010. In November 2013 he spent time in Llandough Hospital and in September 2014 was admitted on a full time basis to the St Barrucs unit a small unit for male patients at Llandough Hospital. It was known that he was prone t0 seizures which were believed to be related to his progressive dementia On the 9th September 2015 at about 9am in the morning he suffered a witnessed seizure which caused to fall to the floor and sustain a serious injury to his head. He was put to bed and remained there until approximately 7 0 clock in the evening when concern was raised for his welfare: There were incomplete and inappropriate physical and neuro observations undertaken of him during this period. Upon his admission to hospital a life threatening injury was suspected. This was subsequently shown at post mortem examination: He passed away within two hours of admission at the University Hospital of Wales in the early hours of morning on the 10h September 2015.

Action should be taken

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

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