University Hospitals Birmingham NHS Trust
NHS / Health Body
Action Taken
The Trust has deployed an ED-specific MEWS Observation Chart for use in the BHH and Good Hope EDs, and the Solihull Minor Injuries Unit; the ED directorate has circulated an email to Divisional Directors across HGS sites disseminating the ED MEWS SOP; the nurse responsible for the care of Mrs Allen has received a period of supervised practice and completed targeted objectives. (AI summary)
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Dear Mrs Hunt INQUEST INTO THE DEATH OF MRS KATHLEEN MARGARET ALLEN REPORT TO PREVENT FUTURE DEATHS write in response to your letter dated July 2018, regarding the Regulation 28 Report made by Miss Emma Brown, Area Coroner; following her investigation and inquest into the death of Mrs Kathleen Margaret Allen on 27 June 2018. University Hospitals Birmingham NHS Foundation Trust (the "Trust") has carefully considered the important matters of concern raised within the Prevention to Prevent Future Deaths Report and the Trust's response is as follows: The Trust recognises the concerns with regards to the apparent inconsistent approach to the MEWS Standard Operating Procedure (SOP) in BHH ED and the lack of consideration given to increasing the frequency of patient observations and the lack of escalation t0 the Nurse in Charge as the clinical condition of the patient deteriorated: The MEWS escalation pathway in ED does differ from that which applies to the wards. As the Area Coroner identified , the escalation pathway documented on the back of Mrs Allen's MEWS Observation Chart required, for MEWS score of between and 3, consideration of increasing the frequency of observations and escalation to the Nurse in Charge: In ED, however; for MEWS score between and 3, there is an expectation that patients observations are completed hourly, but escalation to the Nurse in Charge is not routinely required unless there is an overriding clinical concern or deterioration in the patients condition (that is to say: the MEWS is a safeguard, but clinical staff should not allow it to override their clinical judgement): Chair: Rt Hon Jacqui Smith Chief Executive: Dame Julie Moore Way
The rationale behind the differing escalation pathways is that; on initial presentation, ED patients often have a MEWS score that, on a ward, would trigger escalation: However, for many such patients, the ED rapid assessment, intervention and treatment quickly reduces the MEWS score significantly: If the Trust ward MEWS escalation pathway was applied to ED there would be an unnecessary level of escalation for a cohort of patients with a MEWS between 1-3 who are stable and have management plan that is being followed to allow period of time for the prescribed treatment to take effect: Whilst a different MEWS Observation Chart showing the ED specific escalation pathway has not, historically, been used in ED, as part of their local departmental induction, all ED staff are made aware of the ED specific MEWS escalation pathway and are required to complete MEWS competencies and assessed using clinical scenarios t0 ensure theory and practice is embedded: Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion: Consequently, an ED- specific MEWS Observation Chart has now been deployed for Use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit Further; the ED MEWS SOP is available for all directorate teams to access on the Trust intranet The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use. Finally, in relation to Mrs Allen, the named Nurse who was caring for her had completed all his local departmental competencies: However, irrespective of any confusion regarding the escalation pathway, Mrs Allen should have been escalated to the Nurse in Charge notwithstanding her MEWS between 1 and 3, because of her deterioration. Unfortunately; the Nurse failed to recognise the gradual and subtle changes in Mrs Allen's condition whilst in the Emergency Department The named Nurse responsible for the care of Mrs Allen has received period of supervised practice whilst working in a supernumerary capacity and has completed targeted objectives relating to recognising and care of the deteriorating patient This has been managed using the Trust's Performance and Capability Policy: trust that the above addresses the concerns sufficiently: If you require any further information, please do not hesitate to contact me_
The rationale behind the differing escalation pathways is that; on initial presentation, ED patients often have a MEWS score that, on a ward, would trigger escalation: However, for many such patients, the ED rapid assessment, intervention and treatment quickly reduces the MEWS score significantly: If the Trust ward MEWS escalation pathway was applied to ED there would be an unnecessary level of escalation for a cohort of patients with a MEWS between 1-3 who are stable and have management plan that is being followed to allow period of time for the prescribed treatment to take effect: Whilst a different MEWS Observation Chart showing the ED specific escalation pathway has not, historically, been used in ED, as part of their local departmental induction, all ED staff are made aware of the ED specific MEWS escalation pathway and are required to complete MEWS competencies and assessed using clinical scenarios t0 ensure theory and practice is embedded: Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion: Consequently, an ED- specific MEWS Observation Chart has now been deployed for Use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit Further; the ED MEWS SOP is available for all directorate teams to access on the Trust intranet The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use. Finally, in relation to Mrs Allen, the named Nurse who was caring for her had completed all his local departmental competencies: However, irrespective of any confusion regarding the escalation pathway, Mrs Allen should have been escalated to the Nurse in Charge notwithstanding her MEWS between 1 and 3, because of her deterioration. Unfortunately; the Nurse failed to recognise the gradual and subtle changes in Mrs Allen's condition whilst in the Emergency Department The named Nurse responsible for the care of Mrs Allen has received period of supervised practice whilst working in a supernumerary capacity and has completed targeted objectives relating to recognising and care of the deteriorating patient This has been managed using the Trust's Performance and Capability Policy: trust that the above addresses the concerns sufficiently: If you require any further information, please do not hesitate to contact me_