Source · Prevention of Future Deaths

Hedley Greenland

Ref: 2017-0235 Date: 26 Sep 2017 Coroner: Andrew Barkley Area: South Wales Central Responses identified: 1 / 2 View PDF

Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.

Date 26 Sep 2017

56-day deadline 21 Nov 2017 est.

Responses identified 1 of 2

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A fluid balance chart should have been used by nursing staff t0 monitor fluid intake and urine output There was no evidence that one had been thus rendering it impossible t0 measure urine output which might have indicated & blockage andlor infection: It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output; neither did she consider flushing the catheter: There was no written handover, as the evidence showed is normally the practice; to the incoming nursing team the following morning: There was no clear evidence that the lack of urine output had been noted by the night shift with a view t0 escalating his care_ The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that (2) The qualified nurse on duty overnight 16t/17th December was not trained in male catherisation.

(3) There was no evidence in the medicallnursing notes that the "Catheter Care Bundle" was being used.

(4) The evidence given by two nurses involved in Mr Greenland'$ care revealed a clear lack of understanding; knowledge and training as to how to manage a long term indwelling catheter:

Responses

1 respondent

Response

PDF

Action Taken

The Health Board has implemented a booking and attendance system for community training recorded in an electronic central booking diary and responsibility for catheterisation training is shared between community and secondary care. A catheter passport was introduced in hospital and community settings which will be extended to care homes. (AI summary)

View full response

Dear Mr Barkley, RE_INQUEST HEDLEY GREENLAND write further to the Regulation 28 that you issued following the inquest held on the 2oth September 2017 where the conclusion was a narrative. Abertawe Bro Morgannwg University Health Board provides comprehensive training in regard to urinary catheterisation for all Registered Health Care professionals employed by them: The Health Board also offers this training to registered nurses within the nursing home setting, however they are not obliged to attend: The Health Board encourages providers to nominate staff to attend the various training sessions offered, unfortunately the Health Board is reliant on the provider being able t0 release staff to attend, Since this incident review has been undertaken: The Health Board have now implemented booking and attendance system at community training which is to be recorded using an electronic central booking diary: This will ensure that accurate records are maintained of those who have attended training: It also highlight areas where staff not attended training: Furthermore, where training for catheterisation was shared previously between all Continence Assessors, the Community Continence Service will now take responsibility for training community staff and secondary care will train staff in the secondary care setting: Chairman/Cadeirydd Andrew Davles Interim Chief ExeculivelPrif Welthredwr Dros Dro: Alexandra Howells ABM Headquarlers/ Pencadlys ABM, One Talbot Galeway: Seaway Parade; Baglan Energy Park_ Port Talbot SA12 78R. Telephone: 01639 683344 Flon 01639 683344 FAX: 01639 687675 and 01639 687676 Bwrdd lechyd ABM Yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg RECEIED ABM Universlty Health Board Is the operational name of Aberlawe Bro Morgannwg University Local Health Board wwabm wales nhs uk 2 5 OCT 2017 day will have

This will allow the Continence Service to structure training to the environment staff are working in: Training dates for catheterisation have been shared with Term Care Team to ensure the Health Board are able to monitor attendance from each care home: The Long Care Team work in partnership with Local Authority t0 monitor standards within the care home setting, of this process is to review each care homes training register: homes that are not participating in training will be identified and monitored closely to improve compliance. The Health Board's Nursing home assessors will receive training from the Community Continence Service regarding the management of urinary catheters including documentation: This will provide an opportunity for Health Board Nursing Home assessors to share practice and to measure practice within the Care home setting against agreed standards of practice. Good practice documentation will be shared with the Long Term Care Team on the October 2017 when the Community Continence Service and Long Term Care Team meet: This will include catheter bundles, patient urinary catheter passport for dissemination to Nursing/Care home staff: The care home sector are not currently using the above documentation in totality as the catheter passport is a new document which was recently introduced to the hospital & community setting and will now be extended to care homes. Long Term Care Team will explore the feasibility of setting up a network of 'Continence Champions' where additional training could be provided by the Community Continence Service t0 cascade in all homes: Due to the large number of care home staff in the region the Health Board can offer general level of continence training to care home staff;, however, Continence Champions will be provided with more intense programme of training to ensure can support and advise their colleagues: Additionally, a continence e-leaming link will be shared with Term care team for dissemination to Nursing/Care home staff_ Representative of Community Continence Service to attend the Care home providers meeting: All care homes in the region are represented in these meetings, the meeting allows care home managers and owners to receive updates and awareness sessions on relevant topics relating to health and social care. This is also an opportunity to share lessons learnt and good practice: trust the above information addresses the matters of concern raised in the Regulation 28 report: Please do not hesitate t0 contact me if you require further information:

Report sections

Investigation and inquest

On the 11th January 2017 | commenced an investigation into the death of Hedley Greenland. The investigation concluded at the end of an inquest on 20h September 2017 and the conclusion of the inquest was that of a narrative conclusion - "Hedley Greenland died from the effects of a urine infection in circumstances in which no adequate monitoring of his fluid input and catheter output took place for over 9 hours The medical cause of his death was recorded as Ia. E Coli septicaemia from urinary tract infection 2. Chronic kidney disease, frailty, old age, ischaemic heart disease.

Circumstances of the death

The deceased was residing in the Tynant Nursing Home in Cymmer. He had a number of comobidities which included prostate cancer, As a result of the cancer he was permanently catheterised Around the 14th December 2016 staff suspected he may be suffering with a urinary tract infection and his GP was consulted and a sample of urine sent for analysis: That indicated the presence of two "bugs" and the advice was to monitor his condition and if he were to show signs of systemically unwell further advice should be sought with a view to administering antibiotics. From the 14lh December there was no sign that he was systemically unwell The nurse on duty overnight on Friday 16lh December was made aware of the position and the fact that he had not taken much fluid. She drained his catheter at 00.15am on Saturday 17th December and formed the view that he was dehydrated. She gave him additional fluids but noted that there was no further drainage from the catheter throughout the night until the end of her shift at 7.30 on the 17th December. Around 9.30 on the 17th December it was noted that he had become acutely unwell and upon being re-catheterised approximately 60Oml of purulent urine was drained from the catheter and it was suspected that he maybe septic and an ambulance was called. He was conveyed to hospital to the Princess of Wales Hospital where it was noted that he was bravely iIl and his condition deteriorated and he passed away on the 20th December 2016. being any bag

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

Copies sent to

have sent a copy of my report t0 the3) Minister of Health Welsh Assembly Government

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0235
Date of report: 26 September 2017
Coroner: Andrew Barkley
Coroner area: South Wales Central

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Nov 2017 (estimated).

Sent to

ABMU Health Board

Tynant Nursing Home

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.