Source · Prevention of Future Deaths

Graham Fox

Ref: 2018-0192 Date: 22 Jun 2018 Coroner: Robert Sowersby Area: Avon Responses identified: 1 / 1 View PDF

Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

Date 22 Jun 2018

56-day deadline 17 Aug 2018

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

View full coroner's concerns

(1) The standard NEWS documentation contains a list of scores on the left, corresponding clinical responses in a column on the right My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory: The impression | gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were 'required' when the relevant score was reached were actually necessary The more senior nursing staff were clear that the relevant responses were mandatory, but that was not the impression given by the more junior staff: This evidence (which gave the impression that staff discretion could be applied to the clinical responses) was given after the staff had, apparently, been given additional NEWS training following Mr Fox's death: (2) did not have the benefit of any expert evidence about the process of "re-triggering" patients under NEWS, and am therefore unable to comment on whether it is clinically appropriate: did hear evidence that the practice was commonplace within the hospital. Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website WWW.avon-coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL and

Responses

1 respondent

University Hospitals Bristol NHS Trust NHS / Health Body

PDF

Action Taken

The Trust has implemented an e-observations system on adult in-patient wards that automatically calculates NEWS, prompts observations, and escalates concerns. They are also providing training and education on "revised escalation" and will continue this as they switch to NEWS2 in October 2018. (AI summary)

View full response

Dear Mr Sowersby RE: Inquest 8h June 2018 Mr G_ Fox Regulation 28 Report: Ref:7089 Recognition and response to deterioration in patients, escalation process for patients triggering National Early Warning Score (NEWS) Further to your concerns raised to University Hospitals Bristol NHS Foundation Trust in the format of a Regulation 28 Report, am writing to confirm the Trust's response and actions_ At the inquest; understand that you raised concerns around there being an element of discretion Iclinical judgement applied in determining whether the clinical responses that were required where the relevant EWS was reached were actually necessary and the practice of re-triggering a patient_ Since this incident the Trust has implemented an e-observations system in our adult in-patient wards whereby the patient's physiological measurements are entered electronically into a hand held device , which automatically calculates the national early warning score (NEWS) and prompts the staff member to repeat the observations in required timeframe and to escalate to the relevant clinician in accordance with the Trust's escalation protocol. This system allows for the nurse in charge of the ward to have overslght of all patients showing signs of deterioration in the ward, and also allows oversight out of hours ol deteriorating patients in our hospitals, by the Clinical Site Team; who are highly skilled and experienced nurses who can support ward staff in the management of deleriorating patients. The syslem also allows doctors and senior nurses to review an individual patient's physiological parameters remotely. The analytics in this system also provide visibility of any instances when observations have not been repeated as the escalation protocol to enable targeted training and support to clinical teams if required_ 1 w; University Hospltals Bristol NHS Foundation Trust 20 0117 923 0000 Minlcom 0117 934 9869 Www.uhbristol.nhsuk GCn our hospitals_ (@e the per Aou; ( 1 015481+9

At present; such escalation is completed by telephone or in person; but we will shortly be implementing a further clinical communications system ("CareFlow" whereby the escalation will be automated to the relevant doctor or senior nurse in accordance with the escalation protocol. The CareFlow system is currently being used in a few areas for some elements of clinical communication; With regards to the practice of "re-triggering' this perhaps should be more accurately referred to as "revised escalation" and we have been promoting this terminology within the Trust since we commenced implementing the e-observations system towards the end of 2017 . Some patients do have elevated early warning scores due to a long term condition which is 'normal for them in these situations it can be appropriate for a doctor to document a clear revised escalation plan setting out the circumstances when an escalation should be enacted. In situations where a previously stable patients physiological parameters have prompted the need for a clinical response, and the patient has been reviewed by the appropriate clinician; and the patient has been assessed as being cared for in the correct location within the hospital and there is a clinical management plan with a time for review of its effectiveness; it is appropriate that a revised escalation timeframe can be documented by a doctor_ In all cases, a revised escalation plan states that an escalation should be enacted if a nurse is concerned about the patient's condition. have been supporting the Implementation of the e-observations with a further programme of training and education on revised escalation and will continue do s0 as we switch to the new national early warning score (NEWS2) planned for October 2018_ hope that the information above has answered your concerns and reassures you of the continued focus within University Hospitals Bristol NHS Foundation Trust in improving the recognition and response to deterioration in patients_

Report sections

Investigation and inquest

On 12th July 2017 an investigation commenced into the death of Graham William FOX. The investigation concluded at the end of the inquest on 8 June 2018. The conclusion of the inquest was that he died of (Ia) chronic obstructive pulmonary disease and pneumonia, and (II) left hip fracture (operated) and ankle fractures My narrative conclusion included the following: His condition deteriorated, and overnight from 25 June hospital staff did correctly implement the standardised method of assessment and referral ['NEWS'] that was in use at the time, which meant that he was not seen by a doctor as he should have been, and the seriousness of his condition was not recognised until 26 June, when he was admitted to the Critical Care Unit in which he subsequently died.

Circumstances of the death

Mr Fox had a history of alcohol misuse and had had a fall in the community in which he broke both ankles. He was admitted to hospital and was being monitored using the NEWS system: He had been 're-triggered" by the hospital'$ doctors, so that although normally an oxygen saturation, or a blood pressure reading; below a certain level would add points to the NEWS total, in Mr Foxs case points would not be added unless his score dipped below the new revised ("re-triggered") level: Telephone 01275 461920 Email AvonCoronersTeam@bristol gov.uk Website www.avon-coroner.com The Coroner'$ Court, Old Weston Road, Flax Bourton, BS48 1UL and not

Mr Fox's 'normal' NEWS was 5,after which he was reviewed, "re-triggered" , and when later assessed his score was 5 again (using the new re-triggered means of NEWS assessment) That represented a real-world deterioration in his condition, but because the number itself did not go Up, the nursing staff were relatively unconcerned. The NEWS f 5 was in due course relayed to the on-call doctor, but the doctor did not attend, even though she was on the same ward seeing another patient that evening: Mr Fox then had a series of inadequate observations taken overnight (which were not sufficient to enable any calculation of his NEWS total): By the time his NEWS total was properly calculated in the morning it was 9: he was then admitted to the Critical Care Unit, where his condition deteriorated and he sadly died.

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.

Copies sent to

coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL may

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Report details

Reference: 2018-0192
Date of report: 22 June 2018
Coroner: Robert Sowersby
Coroner area: Avon

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: 17 Aug 2018.

Sent to

University Hospitals Bristol NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.