Source · Prevention of Future Deaths

Margaret Silver

Ref: 2018-0002 Date: 3 Jan 2018 Coroner: Anna Crawford Area: Surrey Responses identified: 1 / 1 View PDF

Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for support were not ensured post-discharge.

Date 3 Jan 2018

56-day deadline 2 May 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The Discharge Summary contained contradictory information in relation to the future prescription of inpatient medication, which led to the medication being discontinued after 21 days when the intention was that it be taken for life.

The fact that the Rivaroxaban had been discontinued was not identified by clinicians at St Peter’s Hospital, despite Mrs Silver attending the hospital on three occasions since her Rivaroxaban had been discontinued, and despite her informing them on 12 January 2016 that she thought it had been discontinued.

Mrs Silver was not provided with the equipment and support which had been recommend by the Occupational Therapist prior to her discharge on 3 February 2016. It was not possible to establish whether the information had in fact been passed on to the care home.

Current procedures may result in inaccurate or contradictory information about prescribed medication being included in hospital discharge summaries.
- The procedures in place for recording a patient’s medication on admission to, and discharge from, hospital may fail to identify circumstances in which a patient is no longer in receipt of potentially life-saving medication.
- The procedures in place for discharge planning may fail to ensure that occupational therapists’ recommendations regarding necessary support and equipment are not passed on to those caring for patients in the community.

Consideration should be given to whether any steps can be taken to address the above concerns.

Responses

1 respondent

Ashford and St Peters Hospitals NHS Trust NHS / Health Body

26 Feb 2018 PDF

Action Taken

The trust is amending the discharge letter template to improve clarity regarding medications. They also intend to introduce electronic prescribing in 2019, and are implementing a 'Red Bag' process to improve communication between providers. (AI summary)

View full response

Dear Ms, Crawford Mrs. Margaret Silver Regulation 28 Report to Prevent Future Deaths Please find below my responses to your concerns raised following the inquest into the death of Mrs: Margaret Silver; Curentprocedures may result in inaccurate or contradictoy information about prescribed medication being included in hospital discharge summares: The Trusts discharge letter template is to be amended t0 enhance safety associated with the generation and oonsequently improve end-user clarity regarding medications AIl infomation pertaining to medications will be included in the same section on the discharge letter; An instruction note to be added to infom the Junior Dctors that all medication instructions shoukd bxe confined to the medication section on the letter: The Trustintends to inbroduce electronic prescribing in 2019. This system utilises electronic systems to facilitate and enhance the communication of a prescription or medicine order; aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trail for the entire medicines use process_ The benefits of ePrescribing for all users and all medicines-related tasks starts with the generation of a legible and complete medication order This information can then be shared among multiple healthcare professionals, allowing reliable access to medicines information without having to hunt down single paper record. Patients first Personal responsibility Passion for excellence Pride in our team Re:

[HB Ashford and St: Peter's Hospitals NiS Foundation Trust
2. The procedures in place for recording a patients medication on admission to, and discharge from; hospital may fail to identify circumstanoesin which a patient is no longer in receipt of potentially life-saving medication: The Trust has commenced a pilot on the 12/h February 2018 on new ways of working with nursing, residential and domiciliary care providers. Since March 2017 a multidisciplinary team of professionals from Ashford and St Peter's NHS Foundation Trust and Adult Social Care have been working with a number of providers to identify better ways of working that will improve outcomes for individuals during and after their stay in hospital. All individuals that receive care from one of the pilot providers will be admitted to hospital with a red bag and a care passport: Inside their red bag will be their 'My Care Passport' , medicines, medication documentation, personal belongings and essential items_ The care passport will give professionals all the necessary information on the delivery of care for that individual, as well their interests, likes and dislikes_ Each care passport will also be updated when the individual leaves hospital, so the provider can quickly understand if need to be supported differently once they are back in the community. In addition to the red we will be facilitating earlier and better communication and information sharing between the wards and the providers both before and after discharge to support the delivery of care once the person is back in their home setting: 3, The procedures in place for discharge planning may fail to ensure that occupational therapists' recommendations regarding necessary support and equipment are not passed on to those caring for patients in the community necessary support and equipment are not passed on to those caring for patients in the community: The 'Red Bag' process described above will improve the multidisciplinary communication between providers. Additionally there be a section added to the discharge summary letter whereby Therapists can provide community providers with appropriate instructions regarding equipment required following discharge. hope the details of the changes we have made to our practices are sufficient to allay the concerns you have raised in your report; Please do not hesitate to contact me should require further details or documentation.

Report sections

Investigation and inquest

An inquest into the death of Margaret Silver was opened on 4 March 2016. It was resumed on 28 November 2017 and concluded on 30 November 2017. The medical cause of death was recorded as: 1a. Aspiration Pneumonia 1b. Fractured Left femur II. Old Pulmonary Emboli, Frailty, Osteoporosis, Hypertensive Heart Disease, Chronic Obstructive Pulmonary Disease.

The inquest concluded with a narrative conclusion, covering the matters set out below.

Circumstances of the death

Mrs Silver was an 85 year old lady who resided at West Hall Care Home in West Byfleet. On 12-15 November 2015 she was admitted to St Peter’s Hospital where she was diagnosed with a deep vein thrombosis. As a result, she was prescribed Rivaroxaban, (an anti-coagulant) for life. However, the Discharge Summary contained contradictory information in relation to the prescription, stating both that it should continue for 21 days and then stop and also that it should continue for life. The inconsistency was not noticed either by Mrs Silver’s GP or the staff at her care home, and as a result, the Rivaroxaban was discontinued on 6 December 2015. Mrs Silver attended St Peter’s Hospital on 1, 12 and 13 January 2016 and on none of those occasions was the lack of Rivaroxaban identified or acted upon by the hospital, despite Mrs Silver telling hospital staff on 12 January 2016 that she thought that she was no longer taking it. Mrs Silver was then readmitted to St Peter’s Hospital from 26 January 2016 to 4 February 2016, at which point she was diagnosed with extensive bilateral Pulmonary Emboli and restarted on Rivaroxaban. Prior to her discharge on 3 February 2016, her mobility was noted to have decreased and the Occupational Therapist recorded that she would require the use of a commode on her return to the care home. It has not been possible to establish whether or not this information was passed on to the care home. On her return to the care home Mrs Silver presented with reduced mobility and on both 5 and 6 February 2016 it is recorded that she struggled to bear her own weight on being assisted to the toilet. However, no changes to her care plan were introduced and she was not provided with a commode. Information regarding her recent hospital admission and reduced mobility was not passed on to the carers assisting her on 7 February 2016. On 7 February 2016 Mrs Silver sustained an assisted fall whilst attempting to transfer from the toilet to her wheelchair, sustaining a fractured left femur. The court found that the fall resulted from her general frailty, which was in part contributed to by the development of the pulmonary emboli.

Following the fall she was readmitted to St Peter’s Hospital. She developed a chest infection on 19 February 2016 and underwent surgery on 22 February 2016. Her condition deteriorated and she died at the hospital on 25 February 2016.

Copies sent to

2. West Hall Care Home3. , Heathcot Medical Practice, Woking4. Care Quality CommissionSignedANNA CRAWFORDDATED this 3rd Day of January 2018

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Report details

Reference: 2018-0002
Date of report: 3 January 2018
Coroner: Anna Crawford
Coroner area: Surrey

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: 2 May 2018 (estimated).

Sent to

Ashford and St Peter’s Hospital NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.